Commander John Scott Hannon Veterans Mental Health Care

Commander John Scott Hannon Veterans

Mental Health Care Improvement Act of 2019

(P.L. 116-171) and Veterans COMPACT Act of

2020 (P.L. 116-214)

July 19, 2021

Congressional Research Service

https://crsreports.congress.gov

R46848


SUMMARY

Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171) and Veterans COMPACT Act of 2020 (P.L. 116-214) Suicide is the 10th leading cause of death in the United States and is a significant contributor to premature mortality. Although suicide rates have increased among the U.S. general population

over the past two decades, veterans are disproportionately affected by suicide. According to the Department of Veterans Affairs (VA), in 2018—the most recent year for which data are available—the suicide rate for veterans was 1.5 times greater than among nonveteran adults

(adjusting for age and sex), and an average of 17.6 veterans died by suicide per day.

VA has named suicide as its top clinical priority for FY2018 to FY2024. In response, the department has implemented numerous initiatives to address veteran suicide and related mental

health concerns. In addition, Congress has expressed sustained interest in reducing veteran suicide and has aimed to reduce such suicides through appropriations and authorizing legislation. Despite these efforts, Congress, VA, and stakeholders continue to express interest in efforts to

further reduce veteran suicide and concern over seemingly limited progress made to date to reduce veteran suicide.

In the 116th Congress, the House and Senate Committees on Veterans’ Affairs (HVAC and SVAC, respectively) focused much of their efforts on veteran suicide prevention, holding several hearings and introducing and enacting legislation on the topic. The Commander John Scott

Hannon Veterans Mental Health Care Improvement Act of 2019 (Hannon Act; P.L. 116-171) and the Veterans Comprehensive Prevention, Access to Care, and Treatment Act of 2020 (Veterans COMPACT Act; P.L. 116-214) were enacted at the end of the 116th Congress and were

developed out of SVAC and HVAC, respectively. Both bills were enacted as part of a compromise between the two committees. Although they are separate, the bills complement each other in their efforts to

increase access to and quality of the Veterans Health Administration (VHA) mental health and suicide prevention services.

Summary of Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171) The Hannon Act was enacted on October 17, 2020. The bill was named after Commander John Scott Hannon, a Navy SEALs member who served in the U.S. Navy for 23 years and died by suicide. Divided into seven titles, the bill addresses five key

areas:

1. Providing more assistance for servicemembers transitioning from the military.

2. Increasing access to mental health care and suicide prevention services for all veterans, and in particular, veterans living in rural areas.

3. Strengthening VHA’s mental health workforce.

4. Providing oversight of VHA’s mental health and suicide prevention services.

5. Investing in and studying mental health treatment, including alternative and complementary treatment approaches.

Summary of Veterans COMPACT Act of 2020 (P.L. 116-214) The Veterans COMPACT Act was enacted on December 5, 2020. The bill is divided into three titles and features nine provisions adapted from different committee members to help prevent veteran suicide. The three key themes, as organized by

title, include

1. Improving the transition to VHA services by helping veterans build networks of support and tracking VA’s outreach to transitioning servicemembers.

R46848

July 19, 2021

Victoria R. Green, Coordinator

Analyst in Health Policy

Sidath Viranga Panangala

Specialist in Veterans Policy

Jared S. Sussman

Analyst in Health Policy

Amanda K. Sarata

Specialist in Health Policy

Bryce H. P. Mendez

Analyst in Defense Health Care Policy

Isaac A. Nicchitta

Research Assistant

For a copy of the full report,

please call 7-5700 or visit www.crs.gov.

The Hannon Act (P.L. 116-171) and the Veterans COMPACT Act (P.L. 116-214)


2. Improving VA’s response to veteran suicide by providing acute crisis care for emergent suicide symptoms and outreach to certain at-risk veterans, creating new programs, and requiring annual VA police crisis intervention training.

3. Improving care and services for women veterans by conducting a gap analysis of VA programs providing assistance to homeless women veterans and requiring a report on locations where women veterans are using VHA care.

Scope of Report This report summarizes the provisions of the Hannon Act and the Veterans COMPACT Act. The report is not intended to provide a comprehensive analysis of every provision in these acts; rather, it provides a brief background and summary of such provisions. The report is organized by each respective law, starting with the Hannon Act , with each summarized by title

and subsequent provisions within the titles. The Appendix of the report includes tables of relevant provisions for the Hannon Act and the Veterans COMPACT Act, respectively, that include an effective date, a required report, or an explicit sunset

date. The report reflects the Hannon Act and the Veterans COMPACT Act at enactment and will not track actions pursuant to required deadlines, nor will this report be updated.

SVAC and HVAC did not produce written reports or release an explanatory statement in the Congressional Record to

accompany the Hannon Act or the Veterans COMPACT Act at the time of passage. Therefore, for some provisions in which committees’ legislative background was not clear, CRS, where applicable, approximates legislative background b y providing contextual information based on testimony at committee hearings, hearing transcripts, or earlier or alternative versions of the

bills, with identical provisions, among other sources. This background should not be used as the official legislative intent of those provisions.



Contents

Background.................................................................................................................... 1

Brief Legislative History............................................................................................. 2 Brief Overview of the Commander John Scott Hannon Veterans Mental Health Care

Improvement Act of 2019 (Hannon Act; P.L. 116-171).................................................. 5 Brief Overview of the Veterans Comprehensive Prevention, Access to Care, and

Treatment Act of 2020 (Veterans COMPACT Act; P.L. 116-214) .................................... 5 Scope of Report......................................................................................................... 6

Provisions in the Commander John Scott Hannon Veterans Mental Health Care

Improvement Act of 2019 .............................................................................................. 9

Title I: Improvement of Transition of Individuals to Services from Department of

Veterans Affairs ...................................................................................................... 9 Title II: Suicide Prevention ....................................................................................... 13 Title III: Programs, Studies, and Guidelines on Mental Health ........................................ 26 Title IV: Oversight of Mental Health Care and Related Services...................................... 31 Title V: Improvement of Mental Health Medical Workforce ........................................... 37 Title VI: Improvement of Care and Services for Women Veterans ................................... 44 Title VII: Other Matters ............................................................................................ 46

Provisions in Veterans COMPACT Act of 2020.................................................................. 51

Title I: Improvement of Transition of Individuals to Services from Department of

Veterans Affairs .................................................................................................... 51 Title II: Suicide Prevention ....................................................................................... 53 Title III: Improvement of Care and Services for Women Veterans.................................... 61

Tables

Table 1. Acronyms Used in This Report .............................................................................. 6

Table A-1. Hannon Act Implementation Dates, Reporting Requirements, and Deadlines........... 63

Table A-2. Veterans COMPACT Act Implementation Dates, Reporting Requirements, and

Deadlines .................................................................................................................. 72

Appendixes

Appendix. Implementation Dates, Reporting Requirements, and Deadlines ............................ 63

Contacts

Author Information ....................................................................................................... 74


Congressional Research Service 1

Background Suicide is the 10th leading cause of death in the United States and is a significant contributor to

premature mortality. There is no single cause of suicide. Rather, it results from a complex interaction between risk factors (e.g., a mental health disorder) and protective factors (e.g.,

community engagement). The interaction of these factors can occur at the individual,

interpersonal, community, and societal level. Although suicide rates have increased among the

U.S. general population over the past two decades,1 veterans are disproportionately affected by

suicide. According to the Department of Veterans Affairs (VA), in the period of 2005-2018,

suicide rates increased more quickly among veterans compared with nonveteran U.S. adults, adjusting for age and sex.2 In 2018—the most recent year for which data are available—the

suicide rate for veterans was 1.5 times greater than among nonveteran adults (adjusting for age and sex), and an average of 17.6 veterans died by suicide per day.3

VA has named suicide as its top clinical priority for FY2018 to FY2024.4 In response, the

department has implemented numerous initiatives to address veteran suicide and related mental

health concerns. VA has described in its national strategy for preventing veteran suicide how these

different interventions are to be implemented to reach all veterans, from the lowest risk to the

highest risk for suicide. This public health approach, which aims to prevent suicide before it occurs by focusing on population-level initiatives, uses multidisciplinary strategies to help diverse

veteran communities, among other things.5 For example, the Veteran Health Administration’s

(VHA’s) recently implemented universal annual screening initiative evaluates all veterans

receiving VHA services for suicidal risk and subsequently assesses suicidal risk among those who

screened positive during the initial screening.6 In the national strategy, VA also emphasizes the need to develop public-private partnerships to advance targeted suicide prevention strategies in

different geographic areas, such as health care provider training and community-specific activities.

Congress has expressed sustained interest in reducing veteran suicide and has aimed to reduce

such suicides through appropriations and authorizing legislation. In FY2021 appropriations,

Congress provided $1.94 billion to VHA for suicide prevention and treatment services,7 an

1 Holly Hedegaard, Sally C. Curtin, and Margaret Warner, “Increase in Suicide Mortality in the United States, 1999 -

2018,” National Center for Health Statistics (NCHS) Data Brief, vol. 362 (April 2020).

2 Office of Mental Health and Suicide Prevention, 2020 National Veteran Suicide Prevention Annual Report,

Department of Veterans Affairs, November 2020, p. 17, https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-

National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf. 3 Office of Mental Health and Suicide Prevention, 2020 National Veteran Suicide Prevention Annual Report,


National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf. Previous VA reports on the suicides per-day

statistic included veterans, current servicemembers, and never federally activated former Guard and Reserve members.

The 2018 statistic does not include current servicemembers or never federally activated former servicemembers.

4 Department of Veterans Affairs, FY2018 - 2024 Strategic Plan, May 31, 2019, https://www.va.gov/oei/docs/va2018-

2024strategicplan.pdf. 5 Office of Mental Health and Suicide Prevention, National Strategy for Preventing Veteran Suicide, 2018-2028,

Department of Veterans Affairs, p. 8, https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-

Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf.

6 U.S. Government Accountability Office, VA Needs Accurate Data and Comprehensive Analyses to Better Understand

On-Campus Suicides, GAO-20-664, September 2020, p. 8, https://www.gao.gov/assets/710/709243.pdf. 7 U.S. Congress, House Committee on Appropriations, Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies, Military Construction, Veterans Affairs, And Related Agencies Appropriations Bill, 2021 , report to



increase of over $40 million from the prior fiscal year.8 Of that amount, $312.6 million was

provided for suicide prevention outreach, which includes VHA prevention-focused activities such

as the Veterans Crisis Line (VCL),9 among other things. Previous Congresses have enacted

several bills to help address veteran suicide, including the Joshua Omvig Veterans Suicide

Prevention Act of 2007 (P.L. 110-110) and the Clay Hunt Suicide Prevention for American

Veterans Act (Clay Hunt SAV Act; P.L. 114-2). Each of these bills included provisions designed to improve VHA’s offering of mental health and suicide prevention services. Despite these

efforts, Congress, VA, and stakeholders continue to express interest in efforts to further reduce

veteran suicide and concern over seemingly limited progress made to date to reduce veteran suicide.

Brief Legislative History

In the 116th Congress, the House and Senate Committees on Veterans’ Affairs (hereinafter

referred to as HVAC and SVAC, respectively) continued to focus on veteran suicide prevention, holding hearings and introducing and enacting legislation on the topic.10 On March 13, 2019, the

Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (S. 785)

was introduced by then ranking member of SVAC Senator Jon Tester and then chairman of SVAC

Senator Jerry Moran. A key feature of the bill was the authorization of a grant program that

requires VA to award grants to certain community-based organizations to provide veteran suicide prevention services.11 During a hearing on the legislation, in May 2019, SVAC heard several views on S. 785. VA testified,

There is much in S. 785 that keys in on what we believe are the right elements, including suicide prevention coordinators at every medical center, a grant program that taps into the resources of the local community, focused research projects and deployment of promising

clinical approaches to suicide prevention, the use of complementary and integrative health care, outreach efforts to reach those veterans that are not in our system of care, and the use

of joint clinical practice guidelines, among other features.12

In June 2019, SVAC held another hearing on engaging communities in preventing veteran

suicide.13 By January 29, 2020, SVAC reported an amended version of S. 785. That version was

accompany H.R. 7609, 116th Cong., 2nd sess., July 13, 2020; H.Rept. 116-445, p. 46.

8 U.S. Congress, House Committee on Appropriations, Subcommittee on Military Construction, Veterans Affairs, and

Related Agencies, Military Construction, Veterans Affairs, And Related Agencies Appropriations Bill, 2020 , Report to

accompany H.R. 2745, 116th Cong., 1st sess., May 15, 2019, H.Rept. 116-63, p. 36. 9 In 2007, VHA established a suicide crisis hotline. It was initially called the National Veterans Suicide Prevention

Hotline. In 2011, its name was changed to the Veterans Crisis Line (VCL). In addition to calling, veterans can chat and

text and connect with a counselor. See https://www.veteranscrisisline.net/Default.aspx.

10 See for example, U.S. Congress, House Committee on Vet erans’ Affairs, “Suicide Prevention,”

https://veterans.house.gov/suicide-prevention, and House Committee on Veterans Affairs, “Takano, Roe Issue

Bipartisan Statement on Veteran Suicide Prevention,” press release, March 7, 2019, https://veterans.house.gov/news/

press-releases/takano-roe-issue-bipartisan-statement-veteran-suicide-prevention. 11 38 U.S.C. §1720F note, as added by section 201 of P.L. 116-171.

12 U.S. Congress, Senate Committee on Veterans’ Affairs, Hearing on Pending Legislation, 116th Cong., 1st sess., May

22, 2019, S. HRG. 116-179 (Washington: GPO, 2020), p. 8.

13 U.S. Congress, Senate Committee on Veterans’ Affairs, Harnessing the Power Of Community: Leveraging Veteran

Networks To Tackle Suicide, 116th Cong., 1st sess., June 19, 2019, S. HRG. 116-209 (Washington: GPO, 2020).



then withdrawn and Senators Jerry Moran and Jon Tester proposed an amended version14 to S. 785, which passed the Senate on August 5, 2020.

In the House, on June 26, 2019, Representatives Jack Bergman and Chrissy Houlahan introduced the Improve Well-Being for Veterans Act (H.R. 3495), which would have required VA to award

grants to eligible community-based organizations to provide suicide prevention services. This

program was substantively similar to the suicide prevention grant program included in S. 785. In

September 2019, HVAC held a hearing on H.R. 3495 and other bills. Regarding the grant

program that would be established by H.R. 3495, VA stated that “VA’s efforts to reduce the incidence of suicidal ideations and behavior (and suicide completions) among all Veterans could

be complemented by partnering with community-based providers who are able to replicate VA’s

suicide prevention programs in the community and to connect with Veterans that are currently beyond VA’s reach.”15

In November 2019, HVAC held another hearing on both H.R. 3495 and a discussion draft bill to

establish a pilot program for the issuance of grants to eligible entities for suicide prevention

activities, for which the department stated it would provide its views in a separate letter to the

committee.16 While some HVAC Members supported the grant program as outlined in H.R. 3495 and the discussion draft bill,17 in his opening remarks, Chairman Mark Takano of HVAC, addressed several concerns he had regarding the grant program as outlined in H.R. 3495:

While I agree with the underlying intent of H.R. 3495, I do have significant concerns. First, this bill would allow VA grants to fund community-based clinical care and would clearly

circumvent the MISSION Act that streamlined clinical care under one program. Instead this legislation creates a separate lane for care in the community without critical safeguards and accountability measures in place…. Second, H.R. 3495, as introduced would provide

direct temporary cash assistance to veterans, their families, and anyone else who may live with them. My understanding is that cash assistance to veterans needs further, careful consideration and should be taken up in separate legislation.... H.R. 3495 as introduced

authorizes the VA Secretary to award grants to organizations unbound to any performance criteria and irrespective of whether there is demonstrated local need for the services

provided by these organizations. Funding decisions should be driven by local coordinating organizations who have the pulse on their communities and regions. The coordination should be as local as possible.... Without local need and metrics tied to the award of grant

funding, this is not consistent with the policy goal of reaching the 60 percent of veterans at risk for suicide who are not connected with VA.18

14 SA 25940.

15 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Statement of Teresa Boyd,

Assistant Deputy Under Secretary For Health For Clinical Operations, Veterans Health Administration (VHA)

Department Of Veterans Affairs (VA), legislative hearing on H.R. 3636; H.R. 2972; H.R. 3036; H.R. 2798; H.R. 2645;

H.R. 2681; H.R. 3224; H.R. 2982; H.R. 2752; H.R. 2628; H.R. 2816; H.R. 1527; H.R. 1163; H.R. 3798; H.R. 3867;

H.R. 4096; and a draft bill, to establish in the Department of Veterans Affairs the Office of Women’s Health, and for

other purposes, 116 th Cong., 1st sess., September 11, 2019. 16 U.S. Congress, House Committee on Veterans’ Affairs, Statement of Robert L. Wilkie Secretary Department Of

Veterans Affairs (VA), legislative hearing on H.R. 3495, and a draft bill, to establish a pilot program for the issuance of

grants to eligible entities, 116th Cong., 1st sess., November 20, 2019.

17 See for example, U.S. Congress, House Committee on Veterans’ Affairs, Opening Statement of Ranking Member

Roe, legislative hearing on H.R. 3495, and a draft bill, to establish a pilot program for the issuance of grants to eligible

entities, 116th Cong., 1st sess., November 20, 2019. See House Committee on Veterans’ Affairs Republicans, “Press

Releases,” November 20, 2019, https://republicans-veterans.house.gov/news/documentsingle.aspx?DocumentID=5550. 18 U.S. Congress, House Committee on Veterans’ Affairs, Opening Statement of Chairman Takano , legislative hearing

on H.R. 3495, and a draft bill, to establish a pilot program for the issuance of grants to eligible entities, 116 th Cong., 1st



On September 10, 2020, HVAC held a legislative hearing on numerous measures related to

suicide prevention and veterans’ behavioral health, not including H.R. 3495.19 At the hearing, VA

submitted written testimony and strongly opposed the bills under consideration by HVAC, stating that many of the bills and their provisions were very similar to provisions in S. 785:

We note that twelve of the bills on the agenda have provisions with elements that appear

very similar to (or have significant commonality with) those in S. 785, the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019, which passed

the Senate unanimously by voice vote on August 5, 2020…. VA testified on the introduced version of S. 785 on May 22, 2019. Through a substantial, wide-ranging effort involving technical assistance exchanges and discussions over more than a year and a half, VA has

brought clinical, programmatic, and legal expertise to bear with SVAC staff to effect improvements to the Senate-passed version of S. 785. Many of the bills ... do not reflect that technical assistance. We ... instead urge the House of Representatives to pass S. 785,

the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019.20

During the 116th Congress, HVAC Chairman Takano adopted a strategy of suicide prevention

generally consistent with the Centers for Disease Control and Prevention’s (CDC’s) Seven Core Strategies for Suicide Prevention.21 Legislation advanced through the committee by Chairman

Takano largely followed the tenets of this public health approach. On September 14, 2020, the

Veterans Comprehensive Prevention, Access to Care, and Treatment (COMPACT) Act of 2020

(H.R. 8247) was introduced by Chairman Takano. Within H.R. 8247, a significant provision was

the authorization of VA to provide emergent suicide care to eligible veterans without requiring

payment.22 This new requirement expanded upon existing VHA policy that would allow for emergent mental health care, but such care was limited to certain individuals and may have

required payment under some circumstances.23 H.R. 8247 did not include any provisions

sess., November 20, 2019. See House Committee on Veterans’ Affairs, “Chairman Takano: ‘In order to mitigate

veteran suicide, we need new solutions,’” press release, November 20, 2019, https://veterans.house.gov/news/press-

releases/chairman-takano-in-order-to-mitigate-veteran-suicide-we-need-new-solutions.

19 U.S. Congress, House Committee on Veterans’ Affairs, Full Committee Legislative Hearing on H.R.7541; H.R.

7504; H.R. 7784; H.R. 7879; H.R. 7747; H.R. 7888; H.R. 7964; H.R. 3450; H.R. 3788; H.R. 3826; H.R. 6092; H.R.

7469; H.R. 8005; H.R. 8033; H.R. 8084; H.R. 8068; H.R. 8149; H.R. 8148; H.R. 8108; H.R. 8144; H.R. 8145; H.R.

8130; H.R. 8107; H.R. 8147; Discussion Draft - ANS for Veterans’ ACCESS Act; Discussion Draft – Veterans

Comprehensive Prevention, Access to Care, and Treatment Act of 2020; Discussion Draft - Ensuring Veterans’ Smooth

Transition Act; Discussion Draft - VA Research Technology Act; Discussion Draft - VA High Altitude and Suicide

Research Act; Discussion Draft - VA Expanded Care Hours Act, and Discussion Draft - Veterans Burn Pits Exposure

Recognition Act of 2020, 116th Cong., 2nd sess., September 10, 2020. 20 Statement for the Record Department of Veterans Affairs, U.S. Congress, House Committee on Veterans’ Affairs,

Full Committee Legislative Hearing on H.R.7541; H.R. 7504; H.R. 7784; H.R. 7879; H.R. 7747; H.R. 7888; H.R.

7964; H.R. 3450; H.R. 3788; H.R. 3826; H.R. 6092; H.R. 7469; H.R. 8005; H.R. 8033; H.R. 8084; H .R. 8068; H.R.

8149; H.R. 8148; H.R. 8108; H.R. 8144; H.R. 8145; H.R. 8130; H.R. 8107; H.R. 8147 ; Discussion Draft - ANS for

Veterans’ ACCESS Act; Discussion Draft – Veterans Comprehensive Prevention, Access to Care, and Treatment Act of

2020; Discussion Draft - Ensuring Veterans’ Smooth Transition Act; Discussion Draft - VA Research Technology Act;

Discussion Draft - VA High Altitude and Suicide Research Act; Discussion Draft - VA Expanded Care Hours Act, and

Discussion Draft - Veterans Burn Pits Exposure Recognition Act of 2020, 116th Cong., 2nd sess., September 10, 2020. 21 Deb Stone, Kristin Holland, Brad Bartholow, et al., Preventing Suicide: A Technical Package of Policy, Programs,

and Practices, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease

Control and Prevention (CDC), Atlanta, GA, 2017, https://www.cdc.gov/violenceprevention/pdf/

suicideTechnicalPackage.pdf.

22 38 U.S.C. §1720J.

23 For more information, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions.



authorizing a suicide prevention grant program or provisions related to the suicide prevention grant program included in H.R. 3495 and S. 785.

In a compromise between SVAC and HVAC,24 the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019 (Hannon Act; P.L. 116-171) and the Veterans

Comprehensive Prevention, Access to Care, and Treatment Act of 2020 (Veterans COMPACT

Act; P.L. 116-214) were enacted at the end of the 116th Congress. Although the bills are separate,

they complement each other in their efforts to increase access to and the quality of VHA mental health and suicide prevention services.

Brief Overview of the Commander John Scott Hannon Veterans

Mental Health Care Improvement Act of 2019 (Hannon Act; P.L.

116-171)

The Hannon Act, enacted on October 17, 2020, was named after Commander John Scott Hannon,

a Navy SEALs member who served in the U.S. Navy for 23 years and died by suicide.25 Divided into seven titles, this legislation addresses five key areas, as stated by its co-sponsors, Senators Jon Tester and Jerry Moran.26 These areas include the following:

1. Providing more assistance for servicemembers transitioning from the military (Title I: Improvement of Transition of Individuals to Services from Department

of Veterans Affairs).

2. Increasing access to mental health care and suicide prevention services for all

veterans, and in particular, veterans living in rural areas (Title II: Suicide Prevention; Title VI: Improvement of Care and Services for Women Veterans;

Title VII: Other Matters).

3. Strengthening VHA’s mental health workforce (Title V: Improvement of Mental

Health Medical Workforce; Title VII: Other Matters).

4. Oversight of VHA’s mental health and suicide prevention services (Title IV:

Oversight of Mental Health Care and Related Services).

5. Investment and study into mental health treatment, including alternative and

complementary treatment approaches (Title II: Suicide Prevention; Title III:

Programs, Studies, and Guidelines on Mental Health; Title VII: Other Matters).

Brief Overview of the Veterans Comprehensive Prevention, Access

to Care, and Treatment Act of 2020 (Veterans COMPACT Act; P.L.

116-214)

The Veterans COMPACT Act was enacted on December 5, 2020. The bill is divided into three

titles and features nine provisions adapted from bills originally introduced by different committee

24 U.S. Congress, Senate Committee on Veterans’ Affairs, “ Senator Moran Applauds Deal to Pass Landmark Veteran

Mental Health & Suicide Prevention Legislation ,” September 22, 2020, https://www.veterans.senate.gov/newsroom/

news/senator-moran-applauds-deal-to-pass-landmark-veteran-mental-health-and-suicide-prevention-legislation.

25 U.S. Senator Jon Tester, “Tester’s Groundbreaking Commander John Scott Hannon Veterans Mental Health and

Suicide Prevention Bill Signed into Law,” October 17, 2020, https://www.tester.senate.gov/?p=press_release&id=7817. 26 U.S. Senator Jon Tester, “ Tester, Moran Introduce Landmark Veterans Mental Health and Suicide Prevention Bill ,”

March 13, 2019, https://www.veterans.senate.gov/newsroom/minority-news/tester-moran-introduce-landmark-veterans-

mental-health-and-suicide-prevention-bill.



members to help prevent veteran suicide. The three key themes, as organized by title, include the following:

1. Improving the transition to VHA services by helping veterans build networks of support and tracking VA’s outreach to transitioning servicemembers (Title I:

Improvement of Transition of Individuals to Services from the Department of

Veterans Affairs).

2. Improving VA’s response to veteran suicide by providing acute crisis care for emergent suicide symptoms and outreach to certain at-risk veterans, creating new

programs, and requiring annual VA police crisis intervention training (Title II:

Suicide Prevention).

3. Improving care and services for women veterans by conducting a gap analysis of VA programs providing assistance to homeless women veterans and requiring a

report on locations where women veterans are using VHA care (Title III:

Improvement of Care and Services for Women Veterans).

Scope of Report

This CRS report summarizes the provisions of the Hannon Act and the Veterans COMPACT Act.

The report does not provide a comprehensive analysis of every provision in these acts; rather, it

provides a brief background and summary of such provisions. The report is organized by each respective law, starting with the Hannon Act. Each bill is summarized by title and subsequent

provisions within the titles. The report reflects the Hannon Act and the Veterans COMPACT Act

at enactment and will not track actions pursuant to required deadlines, nor will this report be updated.

SVAC and HVAC did not produce written reports or release an explanatory statement in the

Congressional Record to accompany the Hannon Act or the Veterans COMPACT Act at the time

of passage. Therefore, for some provisions in which either committees’ legislative background

was not clear, CRS, where applicable, approximates legislative background by providing contextual information based on testimony at committee hearings, hearing transcripts, or earlier

or alternative versions of the bills with identical provisions, among other sources. The

background provided for provisions described in this report should not be used as the official legislative intent of those provisions.

Throughout this report, unless otherwise stated, “the Secretary” refers to the Secretary of Veterans

Affairs, and “department” or “VA” means the U.S. Department of Veterans Affairs. Other

commonly used acronyms in this report are listed in Table 1. In addition, “this section” refers to matters addressed under that specific action of the act, unless otherwise noted.

Table 1. Acronyms Used in This Report

CBO Congressional Budget Office

CBOC Community-Based Outpatient Clinic

CCI Center for Compassionate Innovation

CDC Centers for Disease Control and Prevention

C.F.R. Code of Federal Regulations

CIH Complementary and Integrative Health

COVER Creating Options for Veterans’ Expedited Recovery Commission

CPG Clinical Practice Guideline

DOD Department of Defense



DHS Department of Homeland Security

FDA Food and Drug Administration

GAO Government Accountability Office

HBOT Hyperbaric Oxygen Therapy

HHS Department of Health and Human Services

HIPAA Health Insurance Portability and Accountability Act of 1996

HVAC House Committee on Veterans’ Affairs

LGBTQ Lesbian, Gay, Bisexual, Transgender, or Queer

LPMHC Licensed Professional Mental Health Counselor

MILCON-VA Senate and House Committees on Appropriations, Subcommittees on Military

Construction, Veterans Affairs, and Related Agencies

MFT Marriage and Family Therapist

NAMI National Alliance on Mental Illness

NAL Nurse Advice Line

NASEM National Academies of Sciences, Engineering, and Medicine

NCA National Cemetery Administration

NIMH National Institute of Mental Health

NIST National Institute of Science and Technology

OMHSP Office of Mental Health and Suicide Prevention

OPM U.S. Office of Personnel Management

OTH Other Than Honorable

PACT Patient-Aligned Care Team

PREVENTS President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide

PTSD Posttraumatic Stress Disorder

REACH VET Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment

RCS Readjustment Counseling Service

SAFE VET Suicide Assessment and Follow-up Engagement: Veteran Emergency Treatment

SAMHSA Substance Abuse and Mental Health Services Administration

SMI Serious Mental Illness

SPC Suicide Prevention Coordinator

SPED Safety Planning in Emergency Departments

SVAC Senate Committee on Veterans’ Affairs

TBI Traumatic Brain Injury

U.S.C. United States Code

VA Department of Veterans Affairs

VAMC Veterans Affairs Medical Center

VBA Veterans Benefits Administration

VCCP Veterans Community Care Program

VCL Veterans Crisis Line

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

VSO Veterans Service Organization



Budgetary Impact

This report does not discuss cost estimates for all provisions; however, the Congressional Budget

Office (CBO) provided a cost estimate of the Hannon Act.27 Overall, the Hannon Act is expected

to increase federal deficits by $277 million over the 2020-2025 year period. The estimate breaks down outlays into the following categories:

mental health research,

suicide prevention,

hearing aid specialists,

telehealth,

treatment guidelines,

scholarships for readjustment counselors,

mental health programs,

pilot program on nontraditional therapy, and

reports and studies.

The most significant spending would result from the mental health research and suicide prevention categories. Regarding mental health research, Section 305 of the Hannon Act requires

VA to collect medical information from veterans receiving VHA care and to make anonymized

data available to VA and non-VA researchers. CBO estimates that this effort would cost $94

million from 2020 to 2025. Regarding suicide prevention, Section 201 of the Hannon Act requires

VA to award grants to certain community-based organizations that will provide suicide prevention

services for veterans and their families. CBO estimates that implementing this effort, including program expenses beyond awarding of the grants, would cost $80 million from 2020 to 2025.

At the time of this report’s publication, CBO has not yet provided a cost estimate for the Veterans COMPACT Act. However, CBO has provided cost estimates for legislation with similar intent.

For example, the Sergeant Daniel Somers Veterans Network Support Act of 2019 was introduced

and passed by the Senate in the 116th Congress.28 The bill is identical to Section 101 of the

Veterans COMPACT Act, which requires the Secretary to establish a pilot program that would

allow veterans, before separating from service, to select up to 10 people, to whom VA would

provide information regarding VA services and benefits. CBO estimates that implementing this pilot program would cost $2 million over the 2020 to 2025 period.29

27 Congressional Budget Office (CBO), “At a Glance: S. 785, Commander John Scott Hannon Veterans Mental Health

Care Improvement Act of 2019,” March 23, 2020, https://www.cbo.gov/system/files/2020-03/s0785.pdf.

28 S. 2864 (116th Congress).

29 Congressional Budget Office, “ S. 2864, Sergeant Daniel Somers Veterans Network Support Act of 2019 ,” February

19, 2020, https://www.cbo.gov/system/files/2020-02/s2864.pdf.



Provisions in the Commander John Scott Hannon

Veterans Mental Health Care Improvement Act of

2019

Title I: Improvement of Transition of Individuals to Services from

Department of Veterans Affairs

The period of transition from active duty military service to veteran status is a time of heightened

risk for suicide.30 Studies have shown that “most suicide attempts by those who are or will

become veterans occur following separation from military service.”31 This title includes

provisions to address the risk associated with this period. Such provisions include requiring VA to

(1) develop and make public a strategic plan on the provision of VA health care to any veteran during a one-year period following the discharge or release of the veteran from active duty; (2)

review records of former servicemembers who have died by suicide within the year following separation; and (3) submit and develop reports on relevant VHA suicide prevention programs.

Section 101: Strategic Plan on Expansion of Health Care Coverage for Veterans

Transitioning from Service in the Armed Forces

Background

VA reports that “veterans are most vulnerable in the first three months following separation from

military service, although suicide risk remains elevated for years after the transition.”32

Furthermore, VA has stated that the first 12 months after separation from service is a period marked by a high risk for suicide.33 On January 9, 2018, President Trump signed Executive Order

(EO) 13822, “Supporting our Veterans During Their Transition from Uniformed Service to

Civilian Life,” which mandated the creation of a Joint Action Plan by VA, DOD, and the

Department of Homeland Security (DHS) to provide transitioning servicemembers with seamless

access to mental health treatment and suicide prevention resources for at least one year following their discharge, separation, or retirement. Based on this mandate, VA began to implement

programs to assist newly discharged veterans to enroll in the VA health care system.34 However,

30 Department of Veterans Affairs, 2019 Annual Report: VA Mental Health Program and Suicide Prevention Services

Independent Evaluation, October 2019, p. 188.

31 Department of Veterans Affairs, Help with Readjustment and Social Support Needed for Veterans Transitioning from

Military Service, From Science to Practice, Using Research to Promote Safety and Prevent Suicide, 2019,

https://www.mentalhealth.va.gov/suicide_prevention/docs/Literature_Review_Military_Separation_508_FINAL_05-

24-2019.pdf. 32 Department of Veterans Affairs, Help with Readjustment and Social Support Needed for Veterans Transitioning from

Military Service, From Science to Practice, Using Research to Promote Safety and Prevent Suicide, 2019,

https://www.mentalhealth.va.gov/suicide_prevention/docs/Literature_Review_Military_Separation_508_FINAL_05-

24-2019.pdf.

33 U.S. Congress, House Committee on Veterans’ Affairs, Caring for Veterans in Crisis: Ensuring a Comprehensive

Health System Approach, Statement of Ms. Renee Oshinski, Deputy Under Secretary for Health for Operations and

Management, Department of Veterans Affairs, Veterans Health Administration, 116 th Cong., 2nd sess., January 29,

2020. 34 U.S. Congress, House Committee on Veterans;’ Affairs, Caring for Veterans in Crisis: Ensuring a Comprehensive



veterans would still need to meet the basic eligibility criteria for enrollment, such as (1) meeting

the statutory definition of a “veteran,” meaning an “individual who served in the active military,

naval, or air service and who was discharged or released under conditions other than

dishonorable”;35 (2) meeting the statutory definition of “active duty,” meaning full-time duty in

the Armed Forces, other than active duty for training;36 and (3) having served a minimum period

of 24 months of continuous active duty, among other factors.37 There are several exceptions and special rules to these basic eligibility criteria.38

Provision

Section 101(a) requires the Secretary, no later than one year after the date of the enactment (i.e. ,

October 17, 2021), to submit a strategic plan to SVAC and HVAC on the provision of VA health

care to any veteran during a one-year period following the discharge or release of the veteran from active duty. The strategic plan must also be published on the VA website. In developing this

strategic plan, the Secretary is required to consult with the Secretary of Defense. The strategic plan must include the following elements:

an identification of general goals and objectives for the provision of health care

to recently discharged or released veterans;

a description of how such goals and objectives could be achieved, including, among other things, a description of the use of existing personnel, information,

technology, facilities, public and private partnerships; a description of the

anticipated need for additional resources; and associated costs;

an analysis of the anticipated health care needs, including mental health care, for

such veterans, separated by geographic area;

an analysis of whether recently discharged or released veterans are eligible to

enroll in the VA health care system;

a description of activities designed to promote the availability VA health care,

including outreach to members of the Armed Forces though the Transition

Assistance Program (TAP);39

a description of legislative or administrative action required to implement the

strategic plan; and

a description of how the strategic plan would further the ongoing initiatives of

EO 13822, “Supporting our Veterans During Their Transition from Uniformed

Service to Civilian Life,” signed by President Trump on January 9, 2018.

Health System Approach, Statement of Ms. Renee Oshinski, 116 th Cong., 2nd sess., January 29, 2020.

35 38 U.S.C. §101(2). Section 926 of the William M. (Mac) Thornberry National Defense Authorization Act for Fiscal

Year 2021 (P.L. 116-283) amended the term “veteran” to include “ space service.” The Office of the Law Revision

Counsel of the U.S. House of Representatives has not codified this change as of the date of this report.

36 38 U.S.C. §101(21). 37 38 U.S.C. §5303A or exceptions at 38 U.S.C. §5303A(b)(3).

38 For more information on current eligibility and enrollment in the VA health care system, see CRS Report R42747,

Health Care for Veterans: Answers to Frequently Asked Questions.

39 For more information about the Transition Assistance Program, see CRS In Focus IF10347, Military Transition

Assistance Program (TAP): An Overview.



Section 102: Review of Records of Former Members of the Armed Forces Who

Die by Suicide Within One Year of Separation from the Armed Forces

Background

Since at least 2005, suicide rates among military and veteran populations have consistently been

higher than those among U.S. general population. During calendar year 2018, the Department of Defense (DOD) recorded the following suicide rates among different military populations: 24.9

per 100,000 for active duty servicemembers, 22.9 per 100,000 for reservists,40 and 30.8 per

100,000 for members of the National Guard.41 During calendar year 2018, VA recorded a suicide

rate of 27.5 per 100,000 among veterans.42 In comparison, the suicide rate for the (nonveteran)

U.S. general population was 18.2 per 100,000 during the same time period.43 Suicide and suicidal ideation has remained a top issue of concern for both DOD and VA. 44 In recent years, Congress

has authorized numerous provisions to enhance DOD and VA suicide prevention efforts, improve data collection and reporting, and expand access to mental health care.

Provision

Section 102 directs the Secretary and Secretary of Defense to review certain military records of former servicemembers. Section 102(a) defines these servicemembers as those who separated

from the military between October 2015 and October 2020 (i.e., the “five-year period preceding

the date of enactment”) and who died by suicide within one year after separating. The Secretaries

are required to review DOD service treatment records, military training records, and personnel

records to identify and consider certain demographic information and potential or known risk factors for suicide or suicidal ideation. Risk factors include exposure to violence or suicide,

housing or financial instability, legal or vocational problems, and limited access to health care. In

addition, the review is to identify whether such individuals were referred to the VA’s transition

assistance program (i.e., Solid Start).45 DOD and VA are to submit a report to the House and

Senate Committees on Armed Services, SVAC, and HVAC, no later than three years after enactment (i.e., October 17, 2023), providing aggregated results of their review of former servicemember records.

40 Excludes members of the National Guard. 41 Department of Defense, Annual Suicide Report, Calendar Year 2019 , August 20, 2020, p. 10, https://www.dspo.mil/

Portals/113/Documents/CY2019%20Suicide%20Report/

DoD%20Calendar%20Year%20CY%202019%20Annual%20Suicide%20Report.pdf.

42 Department of Veterans Affairs, National Veteran Suicide Prevention Annual Report, 2020, p. 5,

https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-

2020-508.pdf.

43 Department of Veterans Affairs, National Veteran Suicide Prevention Annual Report, 2020, p. 5. 44 VA and DOD define suicidal ideation as “ thoughts of engaging in suicide-related behavior.” Department of Veterans

Affairs, “VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide ,” May

2019, p. 63, https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCP GFinal5088212019.pdf.

For more on DOD suicide prevention and response, see CRS In Focus IF10876, Military Suicide Prevention and

Response.

45 Solid Start is a VA-administered transition assistance program that conducts outreach to newly separated

servicemembers. The program offers new veterans education and assistance with accessing certain VA benefits. For

more on Solid Start, see https://benefits.va.gov/transition/solid-start.asp.



Section 103: Report on REACH VET Program of Department of

Veterans Affairs

Background

The Recovery Engagement and Coordination for Health—Veterans Enhanced Treatment

(REACH VET) program was launched across VA Medical Centers (VAMCs) in April 2017 and is run by the Office of Mental Health and Suicide Prevention (OMHSP).46 The program is intended

to help VHA predict which veterans may be at the highest risk for suicide or other related adverse

outcomes. Using a statistical algorithm, REACH VET analyzes existing data such as

demographics, use of VA services, and medications to identify veterans at the highest risk of

suicide in the next month.47 If a veteran is identified, a REACH VET coordinator subsequently identifies the clinician closest to the veteran who will then check on the veteran and review the treatment plan to determine if additional care is needed.

Preliminary VA analyses regarding the impact of REACH VET suggest that the program is associated with fewer inpatient mental health admissions and lower all-cause mortality, among

other outcomes.48 According to VA, REACH VET has identified more than 65,000 veterans since

it began in 2017.49 However, many of these data are preliminary, as evaluation studies are still

underway.50 In addition, the methods used to generate such data are not always made publicly available.

Provision

Section 103 requires the Secretary, no later than 180 days after enactment (i.e., April 15, 2021), to

submit to SVAC and HVAC a report on the REACH VET program. The report is required to

include an assessment of the impact of the REACH VET program on rates of suicide among

veterans and a detailed explanation, with evidence, for why conditions included in the REACH VET were chosen, among other information.

Section 104: Report on Care for Former Members of the Armed Forces with

Other than Honorable Discharge

Background

Section 258 of the Military Construction, Veterans Affairs, and Related Agencies Appropriations

Act, 2018 (P.L. 115-141, as amended by P.L. 115-182 and P.L. 115-251; 38 U.S.C. §1720I),

46 Department of Veterans Affairs, “ Study evaluates VA program that identifies Vets at highest risk for suicide,”

https://www.research.va.gov/currents/0918-Study-evaluates-VA-program-that-identifies-Vets-at-highest-risk-for-

suicide.cfm.

47 Department of Veterans Affairs, FY2021 Congressional Budget Submission, Volume II: Medical Programs and

Information Technology Programs, p. VHA-68, https://www.va.gov/budget/docs/summary/

fy2021VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf . 48 Department of Veterans Affairs, “ Study evaluates VA program that identifies Vets at highest risk for suicide,”

https://www.research.va.gov/currents/0918-Study-evaluates-VA-program-that-identifies-Vets-at-highest-risk-for-

suicide.cfm.



fy2021VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf. 50 U.S. National Library of Medicine, “ REACH VET Program Evaluation (REACH VET) ,” https://clinicaltrials.gov/

ct2/show/NCT03280225.



authorized VA to provide an initial mental health care assessment and subsequent mental or

behavioral health care services to certain former servicemembers, including those who served in the Reserve components and who meet each of the following criteria:

Conditions of discharge: the veteran served on active duty and was discharged

or released under a condition that is not honorable (but not a dishonorable

discharge), or was discharged by court-martial (i.e., those with a dishonorable

discharge or a discharge by court-martial would not be eligible for mental health

care services from VA).

Duration of service: the veteran served for a period of more than 100

cumulative days.

Conditions of service: the veteran (1) was deployed in a theater of combat operations, in support of a contingency operation, or in an area at a time during

which hostilities occurred, including by controlling an unmanned aerial vehicle

(UAV) from a location other than such theater or area; or (2) was the victim of a

physical assault of a sexual nature, a battery of a sexual nature, or sexual

harassment.

Not currently enrolled in VA’s health care system.51

Those veterans with an other than honorable (OTH) administrative discharge and who meet the

above criteria are not required to enroll in VA’s health care system, to meet the minimum active

duty service requirements, or to pay any copayments for mental and behavioral health care services included under VA’s standard medical benefits package.52

The Secretary is required to submit a report at least once annually to SVAC and HVAC on the services provided under this authority.53

Provision

Section 104 amends the reporting requirements under 38 U.S.C. §1720I to specify that the annual report be submitted no later than February 15. In addition, the section prescribes three additional

requirements for the annual report, which must specify (1) the types of mental or behavioral

health care needs treated; (2) the demographics of individuals treated including age, era of service

in the Armed Forces, branch of service in the Armed Forces, and geographic location; and (3) the average number of visits of individuals who were provided mental or behavioral health care.

Title II: Suicide Prevention

In 2018, the suicide rate for veterans was 1.5 times greater than among nonveteran adults (adjusting for age and sex), and an average of 17.6 veterans died by suicide per day.54 VA has

51 38 U.S.C. §1720I.

52 Department of Veterans Affairs, Veterans Health Administration, “Eligibility Determination,” VHA Directive

1601A.02, amended October 15, 2020. 53 38 U.S.C. §1720I(f).

54 Office of Mental Health and Suicide Prevention, 2020 National Veteran Suicide Prevention Annual Report,


National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf. Previous VA reports on the suicides per-day

statistic included veterans, current servicemembers, and never federally activated former Guard and Reserve members.

The 2018 statistic does not include current servicemembers or never federally activated former servicemembers.



named suicide as its top clinical priority for FY2018 to FY2024,55 while recognizing that

coordinated efforts from different stakeholders and across settings can increase the reach of

veteran suicide prevention activities.56 This title includes provisions to address veteran suicide

through a multifactorial approach. Such provisions include requiring VA to (1) award grants to

certain community-based organizations to provide veteran suicide prevention services to eligible

veterans; (2) examine the feasibility of and increase access to complementary and integrative health programs; and (3) examine factors potentially related to veteran suicide. In addition, GAO is required to conduct oversight of VA’s management of veterans at high risk for suicide.

Section 201: Financial Assistance to Certain Entities to Provide or Coordinate

the Provision of Suicide Prevention Services for Eligible Individuals and Their

Families57

Background

As stated elsewhere in this report, the need for community-based engagement to prevent veteran

suicide led to a grant program to address this issue. In its FY2021 budget request to Congress, the

Trump Administration proposed legislation that would allow VA to provide grants to community-

based organizations to “replicate and/or expand VA suicide prevention services.”58 In addition, the

President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide (PREVENTS)59 found that

funding initiatives that support a public health approach are vital to empowering Veterans and preventing suicide at the local level. As existing community-based grants to do this are

limited, additional funding in the short and long term would expand opportunities to identify new effective strategies and ensure that all communities are provided with opportunities to create environments where Veterans will thrive. An expanded, Federal

grant program can also assist in meeting the needs of the community by ensuring that critical data, training, and technical assistance are available and accessible at the program

level.60

PREVENTS recommended developing “a coordinated, interagency Federal funding mechanism

to support, provide resources for, and facilitate the implementation of successful evidence-

informed mental health and suicide prevention programs focused on Veterans and their communities at the State and local levels.”61

55 Department of Veterans Affairs, FY2018 - 2024 Strategic Plan, May 31, 2019, https://www.va.gov/oei/docs/va2018-

2024strategicplan.pdf. 56 Department of Veterans Affairs, “National Strategy for Preventing Veteran Suicide, 2018 -2028,” p. 13,

https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-

Strategy-for-Preventing-Veterans-Suicide.pdf.

57 38 U.S.C. §1720F note. 58 Department of Veterans Affairs, FY2021 Congressional Budget Submission, Volume I: Supplemental Information

and Appendices, Legislative Summary, p. 10.

59 On March 5, 2019, President Trump signed Executive Order (EO) 13861 “The President’s Roadmap to Empower

Veterans and End a National Tragedy of Suicide (PREVENTS)” to address veteran suicide in the United States. For

more information, see https://www.va.gov/PREVENTS/EO-13861.asp.

60 Department of Veterans Affairs, President’s Roadmap to Empower Veterans and End a National Tragedy of Suicide

(PREVENTS), June 17, 2020, p. 46. 61 Department of Veterans Affairs, PREVENTS, p. 46.



Provision

Section 201(a) establishes a new grant program, the Staff Sergeant Parker Gordon Fox Suicide

Prevention Grant Program. The purpose of the grant program is “to reduce veteran suicide

through a community-based grant program to award grants to eligible entities to provide or coordinate suicide prevention services to eligible individuals and their families .”

Financial Assistance and Coordination

Section 201(b) requires the Secretary to award grants to eligible entities to provide or coordinate

the provision of services to eligible individuals and their families to reduce the risk of suicide.

The Secretary is required to implement this grant program, to the extent practicable, in coordination with PREVENTS and in consultation with VA’s OMHSP.

Award of Grants, Grant Amounts, Intervals of Payment, and Matching Funds

Section 201(c) stipulates that based on the suicide prevention services to be provided by an

eligible entity, and the duration of such services, the Secretary must establish a maximum amount

to be awarded under the grant program and intervals of payment for the administration of the

grant. The maximum amount awarded is limited to no more than $750,000 per grantee per fiscal year.

Distribution of Grants and Preference

Section 201(d) stipulates criteria the Secretary is required to consider and follow when

distributing grants. The Secretary may prioritize grants to (1) rural communities; (2) tribal lands;

(3) territories of the United States; (4) medically underserved areas; (5) areas with a high number

or percentage of minority veterans or women veterans; and (6) areas with a high number or percentage of calls to the Veterans Crisis Line (VCL). The Secretary is required to ensure that, to

the extent practicable, grants are distributed to (1) areas of the United States that have

experienced high rates of suicide and suicide attempts by eligible individuals, and (2) eligible

entities that can assist eligible individuals at risk of suicide who are not currently receiving health

care furnished by VA. The Secretary may provide grants to eligible entities that furnish services to

eligible individuals and their families in geographically dispersed areas. Lastly, the Secretary is required to give preference to eligible entities that have demonstrated the ability to provide or coordinate suicide prevention services.

Requirements for Receipt of Grants

Section 201(e) requires that each grantee for the provision of suicide prevention services must

notify eligible recipients that such services are being paid for, in whole or in part, by VA. The section also requires that any suicide prevention plan be developed in consultation with the

eligible recipients and their families. Section 201(e)(3) requires that any grantee coordinate with

the Secretary regarding the provision of clinical services, and inform every veteran who receives

assistance through the grant of the ability to apply for enrollment in the VA health care system. If

a veteran wishes to enroll, the grantee must inform the veteran of a VA point of contact who can assist with enrollment.62 Section 201(e)(4) stipulates that a grantee must submit to the Secretary a

description of such tools and assessments the entity uses or will use to determine the effectiveness

of the suicide prevention services furnished. The description must also include measures and

metrics on the effectiveness of the programming being provided, and may include the effect of

the services furnished on the financial stability of the individual; the mental health status,

62 For more information on current eligibility and enrollment in the VA health care system, see CRS Report R42747,

Health Care for Veterans: Answers to Frequently Asked Questions.



wellbeing, and suicide risk of the individual; and the social support of the individuals receiving

those services. Under Section 201(e)(5), the Secretary shall require each grantee to submit an

annual report to the Secretary that describes the grant projects carried out during the year covered

by the report. The report must include evaluation criteria and data, as specified by the Secretary, and the Secretary may require additional reports, as appropriate.

Application for Grants

Section 201(f) stipulates that an entity seeking a grant is required to submit to the Secretary an

application in such form and manner as prescribed by Secretary. Each application submitted by an eligible applicant must include the following:

a description of proposed suicide prevention services, and the need for those

services;

a detailed plan describing how the applicant proposes to coordinate or deliver

suicide prevention services, including

identification of the community partners, if any, with which the applicant

proposes to work in delivering suicide prevention services;

a description of the arrangements currently in place between the

applicant and community partners with regard to the provision or

coordination of suicide prevention services;

identification of the duration of those partnerships, and a description of the suicide prevention services provided by community partners, if any;

and

identification of local VA suicide prevention coordinators (SPCs) and a

description of how the applicant will communicate with VA SPCs;

a description of the number of eligible individuals and their families that would

be provided suicide prevention services;

an estimate of the number of eligible individuals at risk of suicide and their

families that will be provided suicide prevention services, including the

percentage of those eligible individuals who are not currently receiving care

provided by VA;

evidence of measurable outcomes related to reductions in suicide risk and mood-

related symptoms using validated instruments by the applicant (the applicant’s

community partners, if any);

a description of the managerial and technological capacity of the applicant,

including the following:

to coordinate the provision of suicide prevention services;

to assess on an ongoing basis the needs of eligible individuals and their

families for suicide prevention services;

to coordinate the provision of suicide prevention services with the

services provided by VA;

to adapt suicide prevention services to the needs of eligible individuals

and their families;

to seek continuously new sources of assistance to ensure the continuity of suicide prevention services for eligible individuals and their families

as long as they are determined to be at risk of suicide; and



to measure the effects of suicide prevention services provided by the

applicant or partner organization, on the lives of eligible individuals and

their families who receive such services provided by the organization

using pre- and post-evaluations on validated measures of suicide risk and

mood-related symptoms;

clearly defined objectives for the provision of suicide prevention services;

a description and physical address of the primary location of the applicant;

a description of the geographic area the applicant plans to serve during the grant

award period for which the application applies;

if the applicant is a state or local government or an Indian tribe, the amount of

grant funds proposed to be made available to community partners, if any, through

agreements;

a description of how the applicant will assess the effectiveness of the provision of

grant funds;

an agreement that the applicant would use the measures and metrics provided by

VA; and

any additional application criteria as prescribed the Secretary.

Training and Technical Assistance

Section 201(g) requires the Secretary to provide technical assistance and training in coordination

with the Centers for Disease Control and Prevention (CDC) to grantees (or eligible entities in

receipt of a grant). The technical assistance and training is to involve suicide risk identification

and management, required data collection and sharing, familiarization with appropriate data collection tools, and assistance with data collections for annual reporting requirements, among

other things. The Secretary may provide this technical assistance and training directly or by entering into contracts with public or nonprofit entities.

Administration of Grant Program

Section 201(h) requires the Secretary to establish criteria for the selection of grantees, in

consultation with numerous entities such as veteran service organizations (VSOs), tribal alliances, state departments of veterans affairs, the National Alliance on Mental Illness (NAMI), certain

federal agencies, and institutions of higher education that have expertise in creating measurement

criteria, among other entities and organizations. The section also requires the Secretary to

develop, in consultation with those same entities, a framework for collecting and sharing

information about grantees to improve the services available for eligible individuals and their families based on service type, locality, and eligibility criteria, as well as measures and metrics to

be used by the grantees to determine the effectiveness of the services they are providing. Section

201(h)(4) requires the Secretary, no later than 30 days before the notification of the availability of

grant funding, to provide a report to SVAC, HVAC, and MILCON-VA on the criteria for the award of a grants.

Information on Potential Eligible Individuals

Section 201(i) allows the Secretary to provide eligible grantees information about potential

eligible individuals. This information may include veteran status and enrollment status in the VA

health care system, including whether they are currently receiving care through VA. The Secretary must allow veterans to opt out of having their information shared with eligible grantees.

Duration of the Grant Program



Section 201(j) stipulates that the Secretary is not authorized to award grants on the date that is three years after the date on which the first grant is awarded.

Reporting

Section 201(k) requires the Secretary to submit an interim report to SVAC, HVAC, and

MILCON-VA no later than 18 months after the date on which the first grant is awarded. This report must include the following information:

an assessment of the effectiveness of the grant program;

a list of grantees, and the amount of each grant awarded;

the number of eligible individuals supported by each grantee, including services

provided to family members;

the number of eligible individuals not receiving VA care;

the number of eligible individuals who received a baseline assessment about their

mental health status, well-being, and suicide risk, and who will be measured for

any improvements over time;

the types of data VA was able to collect;

the number and percentage of eligible individuals referred for enrollment in the

VA health care system;

the number of eligible individuals newly enrolled in the VA health care system

based on such referral;

a detailed account of grant expenditures, including executive compensation,

overhead costs, and other indirect costs;

a description of any outreach activities conducted by the grantees; and

the number of ineligible individuals who seek services under the grant program.

Furthermore, Section 201(k)(2) stipulates that the Secretary is required to submit a final report to SVAC, HVAC, and MILCON-VA no later than three years after the award of the first grant and

then annually for the duration of the grant program. The final report would be a follow-up to the

interim report submitted previously, and would include additional information regarding the

effectiveness of the grant program, an assessment of VA’s capacity to provide services to eligible

individuals, feasibility and advisability of extending or expanding the grant program, and any other relevant information.

Third-Party Assessment

Section 201(l) requires the Secretary, no later than 180 days after the start of the grant program, to

enter into a contract with a nongovernment entity with experience in evaluating organizations that

deliver suicide prevention programs. The contracted entity must evaluate the effectiveness of the grant program and compare the results of the grant program to other national programs. The

contracted entity must provide this assessment to the Secretary no later than 24 months after the

start of the grant program. Upon receipt of the assessment the Secretary is required to provide a copy to SVAC, HVAC, and MILCON-VA.

Referral for Care

Section 201(m) stipulates that if a grantee determines that an eligible individual is at risk of

suicide or another mental or behavioral health condition, that individual must be referred to VA

for additional care. The section also stipulates that if a grantee determines that an eligible

individual is provided emergency care and that individual needs further care and services, that



individual must also be referred to VA for further treatment. If the individual declines the referral to VA, any ongoing clinical care provided will be at the expense of the grantee.

Provision of Care to Eligible Individuals

Section 201(n) requires the Secretary, if clinically appropriate, to provide an initial mental health

assessment and mental health or behavioral health care services through the VA health care

system for individuals who are receiving services through the grant program and are referred for care.

Agreements with Community Partners

Section 201(o) allows state or local government or Indian tribe grantees to use grant funds to enter into contracts with community partners for the provision of suicide prevention services.

Authorization of Appropriations

Section 201(p) authorizes a total of $174 million to be appropriated for FY2021 through FY2025.

Definitions

Section 201(q) defines the following terms applicable to the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program.

Appropriate committees of Congress. SVAC, HVAC, MILCON-VA.

Eligible Entity. (1) “an incorporated private institution or foundation in which no part of the net

earnings of which incurs to the benefit of any member, founder, contributor, or individual; and

that has a governing board that would be responsible for the operation of the suicide prevention

services”, (2) a corporation wholly owned and controlled by an organization in which no part of

the net earnings incurs to the benefit of any member, founder, contributor, or individual, and that

has a governing board that would be responsible for the operation of the suicide prevention services, (3) an “Indian tribe”, (4) “a community-based organization that can effectively network

with local civic organizations, regional health systems, and other settings where eligible individuals and their families are likely to have contact”, or (5) a “State or local government.”

Eligible Individual. A person at risk of suicide “who served in the active military, naval, or air

service, and who was discharged or released therefrom under conditions other than

dishonorable”;63 or former servicemembers, including those who served in the Reserve components and who meet each of the following criteria:64

Conditions of discharge: the veteran served on active duty and was discharged or

released under a condition that is not honorable (but not a dishonorable

discharge), or was discharged by court-martial (i.e., those with a dishonorable discharge or a discharge by court-martial would not be eligible for mental health


Duration of service: the veteran served for a period of more than 100 cumulative

days.

Conditions of service: the veteran (1) was deployed in a theater of combat

operations, in support of a contingency operation, or in an area at a time during

which hostilities occurred, including by controlling an unmanned aerial vehicle


Year 2021 (P.L. 116-283) amended the term “veteran” to include “space service.” The Office of the Law Revision

Counsel of the U.S. House of Representatives has not codified this change as of the date of this report. 64 38 U.S.C. §1720I(b).



(UAV) from a location other than such theater or area, or (2) was the victim of a


harassment.

Not currently enrolled in VA’s health care system.

Additional criteria include the following:

Any individual who is a veteran or member of the Armed Forces, including a member of a

reserve component of the Armed Forces, who served on active duty in a theater of combat operations or an area at a time during which hostilities occurred in that area.65

Any individual who is a veteran or member of the Armed Forces, including a member of a reserve component of the Armed Forces, who provided direct emergency medical or mental

health care, or mortuary services to the causalities of combat operations or hostilities, but who at the time was located outside the theater of combat operations or area of hostilities.66

Any individual who is a veteran or member of the Armed Forces, including a member of a reserve component of the Armed Forces, who engaged in combat with an enemy of the

United States or against an opposing military force in a theater of combat operations or an area at a time during which hostilities occurred in that area by remotely controlling an

unmanned aerial vehicle, notwithstanding whether the physical location of such veteran or member during such combat was within such theater of combat operations or area.67

Any individual who is a veteran or member of the Armed Forces, including a member of a reserve component of the Armed Forces, who served

on active service in response to a national emergency or major disaster declared by the President; or

in the National Guard of a State under orders of the chief executive of that State

in response to a disaster or civil disorder in such State.”68

Emergency Treatment. Medical services, professional services, ambulance services, ancillary

care and medication rendered in a medical emergency in which it could be reasonably expected that absence of immediate medical attention would result in serious health consequences.

Family. Family includes a parent, a spouse, a child, a sibling, a step-family member, an extended family member, or any other individual who lives with the eligible individual.

Indian Tribe. “Any Indian tribe, band, nation, or other organized group or community of Indians,

including any Alaska Native village or regional or village corporation as defined in or established

pursuant to the Alaska Native Claims Settlement Act, that is recognized as eligible for the special

programs and services provided by the United States to Indians because of their status as Indians pursuant to the Indian Self-Determination and Education Assistance Act of 1975.”69

Risk of Suicide. Exposure to, or the existence of, any of the following risk factors: mental health

challenges; substance abuse; serious or chronic health conditions or pain; traumatic brain injury; prolonged stress; stressful life events; unemployment; homelessness; recent loss; legal or

financial challenges; previous suicide attempts; family history of suicide; history of abuse,

65 38 U.S.C. §1712A(a)(1)(C)(i).

66 38 U.S.C. §1712A(a)(1)(C)(ii). 67 38 U.S.C. §1712A(a)(1)(C)(iii).

68 38 U.S.C. §1712A(a)(1)(C)(iv).

69 Section 4 of the Native American Housing Assistance and Self-Determination Act (NAHASDA, P.L. 104-330); 25

U.S.C. §4103.



neglect, or trauma. The Secretary may establish a process for determining degrees of suicide risk through regulation.

Rural. Rurality as defined by the Rural-Urban Commuting Areas (RUCA) system.70

Suicide Prevention Services. Suicide prevention services are those that address the needs of

eligible individuals and their families and include, among other things, outreach to identify those

at risk, a baseline mental health screening for risk, peer support services, and other services necessary for improving mental health status and well-being of eligible individuals and their families, including adaptive sports and family counseling.

Veterans Crisis Line (VCL). The VCL is “a toll-free hotline for veterans to be staffed by appropriately trained mental health personnel and available at all times.”71

Veterans Service Organization (VSO). Organizations recognized by VA to prepare, present, and prosecute claims.72

Sections 202 and 203: Analysis on Feasibility and Advisability of the

Department of Veterans Affairs Providing Certain Complementary and

Integrative Health Services; Pilot Program to Provide Veterans Access to

Complementary and Integrative Health Programs through Animal Therapy,

Agritherapy, Sports and Recreation Therapy, Art Therapy, and Posttraumatic

Growth Programs

Background

VA has broad authority to offer health services through the standard medical benefits package if it

is determined by appropriate health care professionals that the care is needed to promote,

preserve, or restore the health of the individual and is in accord with generally accepted standards

of medical practice.73 Under this authority, VA has established a vetting process for including

complementary and integrative health (CIH) services in the standard medical benefits process.74 The vetting process considers the following criteria:

licensing and credentialing;

clinical practice guidelines, current evidence, community standards, and potential

for harm;

veteran demand; and

supports transformation of health care delivery.

70 For more information, see https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/.

71 38 U.S.C. §1720F(h). 72 For more information on VSOs, see CRS Report R46412, Veterans Service Organizations (VSOs): Frequently Asked

Questions; and CRS Report R46428, Veterans Accredited Representatives: Frequently Asked Questions.

73 38 C.F.R. §17.38(b).

74 Department of Veterans Affairs, Veterans Health Administration, “Provision of Complementary and Integrative

Health (CIH),” VHA Directive 1137, p. B-1, May 18, 2017.



Under these criteria, VA has approved a number of CIH approaches for coverage under the VHA

standard medical benefits package (38 C.F.R. §17.38). These include acupuncture, biofeedback, clinical hypnosis, guided imagery, massage therapy, meditation, Tai Chi/Qi Gong, and yoga. 75

Section 931 of the Jason Simcakoski Memorial and Promise Act (Title IX of P.L. 114-198)

established the Creating Options for Veterans’ Expedited Recovery (COVER) Commission,

which was required to examine the evidence-based therapy treatment model used by the Secretary

for treating mental health conditions of veterans and the potential benefits of incorporating CIH

treatments available in nondepartment facilities.76 The COVER Commission published a final report on February 6, 2020.77

The final report of the COVER Commission made a recommendation to “establish an ongoing

research program focused on testing and implementation of promising adjunctive CIH modalities associated with positive mental health, functional outcomes, and wellness that support whole

health and the VA Health Care Transformation Model.”78 This model is the overarching

recommendation of the COVER Commission, and it is intended to transform VA health care delivery from a reductionist to a whole health person-centered approach.79

Provisions

Section 202 requires the Secretary to complete an analysis on the feasibility and advisability of

providing specified CIH treatments. The Secretary is required to complete the analysis no later

than 180 days from enactment of this act (i.e., April 15, 2021). In addition, this section requires

the Secretary to include an assessment of the COVER Commission final report in the

aforementioned analysis. The Secretary is required to submit a report to SVAC and HVAC on the analysis that includes recommendations regarding the furnishing of CIH treatments.

Section 203 requires the Secretary to create a pilot program to provide access to specified CIH

programs no later than 180 days after the date on which the COVER Commission submitted its final report (i.e., July 24, 2020).80 This section specifies that the pilot program provide equine

therapy, other animal therapy, agritherapy, sports and recreation therapy, art therapy, and

posttraumatic growth programs. The pilot program must be conducted at no fewer than five VA

facilities that meet specified criteria. To be eligible for services, veterans must be enrolled in the

VA health care system and have received services within the two-year period preceding the initiation of the pilot program.81 The Secretary is required to carry out the pilot program for at

least three years and must submit an interim report on program progress to SVAC and HVAC no

later than one year after commencement of the pilot program. The Secretary may extend the

duration of the pilot program beyond three years based on the results of the interim report

indicating that it is appropriate to do so. The interim report is required to include, among other

75 Department of Veterans Affairs, Veterans Health Administration, Office of Patient Centered Care and Cultural

Transformation, Integrative Health Coordinating Center (IHCC) Fact Sheet, https://www.va.gov/WHOLEHEALTH/

docs/IHCC_FactSheet_508.pdf.

76 38 U.S.C. §1701 note.

77 Creating Options for Veterans Expedited Recovery (COVER) Commission, Final Report, January 24, 2020,

https://www.va.gov/COVER/docs/COVER-Commission-Final-Report-2020-01-24.PDF. (Hereinafter referred to as

“The COVER Commission Final Report.” 78 The COVER Commission Final Report, p. 42.

79 COVER Commission Final Report, p. 71.

80 The implementation deadline took place prior to enactment of the Hannon Act (October 17, 2020). 81 For information on eligibility and enrollment in VA health care, see CRS Report R42747, Health Care for Veterans:

Answers to Frequently Asked Questions.



things, the number of participants, the types of therapy offered, an assessment of effectiveness,

and the determination of whether the program will be extended beyond three years. The Secretary

is required to submit a final report to SVAC and HVAC no later than 90 days after termination of the pilot program.

Section 204: Department of Veterans Affairs Study of All-Cause Mortality of

Veterans, Including by Suicide, and Review of Staffing Levels of Mental

Health Professionals

Background

Due to combat-related injuries, among other factors, veterans have higher rates of chronic pain,

traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and other mental health

conditions compared with the civilian population. Opioids are primarily prescribed for acute and

chronic pain treatment. Coupled with the addictive properties of opioids and potential subsequent transition to other types of harmful opioids (e.g., heroin), increases in prescribing and use from

the late 1990s until approximately 2012—prompted by a desire to improve pain management—

have resulted in high levels of morbidity and mortality among both veteran and civilian

populations. Benzodiazepines are typically prescribed for anxiety or insomnia, but severe adverse

effects have been associated with chronic use of this medication. Similar to opioids, benzodiazepine prescribing increased from the late 1990s to approximately 2012, but, unlike for

opioids, prescribing still remains at high levels. Further, concomitant opioid and benzodiazepine use is associated with increased rates of unintentional overdose and death, as well as suicide. 82

In a 2013 HVAC hearing on narcotic overprescribing within VHA, Dr. Claudia Bahorik—at the

time, a VHA provider—in her testimony recommended ways to address this issue. Among other

things, she suggested addressing insufficient staffing to more closely monitor veterans receiving

narcotic prescriptions.83 To help monitor narcotic prescriptions, VHA implemented the Opioid

Safety Initiative (OSI) and the Psychotropic Drug Safety Initiative (PDSI) in 2013.84 However, even with these initiatives, it is not clear to what extent opioid and benzodiazepine co-prescribing

in VHA may have contributed to adverse outcomes among veterans. In response to concerns

regarding overprescribing of these medications within VHA, Congress provided funds to

NASEM in FY2018 “to conduct an assessment of the potential overmedication of veterans during

fiscal years 2010 to 2017 that led to suicides, deaths, mental disorders, and combat-related

traumas.”85 NASEM subsequently published a 2019 assessment that, among other things, included examples of observational study protocols to estimate the causal effects of opioid and

82 National Academies of Sciences, Engineering, and Medicine, An Approach to Evaluate the Effects of Concomitant

Prescribing of Opioids and Benzodiazepines on Veteran Deaths and Suicides, Washington, DC, 2019, p. 1,

https://www.nap.edu/read/25532/chapter/2.

83 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Health, Between Peril and Promise:

Facing the Dangers of VA’s Skyrocketing Use of Prescription Painkillers to Treat Veterans, 113th Cong., 1st sess.,

October 10, 2013 (Washington: GPO, 2014). 84 National Academies of Sciences, Engineering, and Medicine, An Approach to Evaluate the Effects of Concomitant

Prescribing of Opioids and Benzodiazepines on Veteran Deaths and Suicides, 2019, p. 2, and VA Office of Inspector

General (OIG), Healthcare Inspection Patient Mental Health Care Issues at a Veterans Integrated Service Network 16

Facility, Department of Veterans Affairs, Washington, DC, January 4, 2018, p. 4, https://www.va.gov/oig/pubs/

VAOIG-16-03576-53.pdf.


Related Agencies, Book 2 of 2; Divisions G-L, committee print, 115 th Cong., 2nd sess., 2018, p. 1575.



benzodiazepine co-prescribing on veteran suicides.86 In FY2020 appropriations report language,

Congress directed VA to work with NASEM to implement the study design specified in the 2019 assessment.87

Prior to enactment of the Hannon Act, Congress introduced other legislation in the 116th Congress

to address this issue.88 Among other things, the proposed legislation would have required VA to

review the number of veterans who died by suicide and were prescribed multiple medications in a

five-year period, and provide a description of the efforts of VHA to maintain appropriate mental health staffing levels.

Provision

Section 204(a) requires the Secretary to enter into an agreement with NASEM under which the

Secretary shall collaborate with the National Academies on a revised study design to fulfill the

goals of the 2019 study design, evaluating the effects of opioids and benzodiazepines on all-cause

mortality of veterans, including suicide, among other things. As required by Section 204(d), the Secretary shall brief SVAC and HVAC on the interim results no later than two years after entering

into the agreement with NASEM. Section 204(e)(1) requires the Secretary, in coordination with

NASEM, to submit a report on the results of the study to SVAC and HVAC no later than 90 days after completion of the study.

Section 204(b) requires GAO, no later than 90 days after enactment (i.e., January 15, 2021), to

conduct a review of staffing levels for mental health professionals within VA, including mental

health counselors, marriage and family therapists, and other appropriate counselors. The review is required to include

a description of barriers to carry out education, training, and hiring of mental

health professionals, as required by 38 U.S.C. §7302(a), and strategies to address

those barriers;

a description of the objective, goals, and timing to increase representation of

counselors and therapists in the VA behavioral health workforce;

an assessment of VA’s development of hiring guidelines for mental health

professionals;

a description of how VA identifies gaps in mental health professional staffing and

determines successful staffing ratios for mental health professionals;

a description of actions taken by the Secretary, in coordination with the Office of

Personnel Management (OPM), to create an occupational series for mental health

professionals; and

a description of actions taken by the Secretary to ensure that the national,

regional, and local professional standards boards for mental health professionals

are composed of only mental health professionals, and that the VA liaison to such

boards is a mental health professional.

As required by Section 204(d), the Secretary shall brief SVAC and HVAC on the interim results

of the review no later than 18 months after enactment (i.e., April 17, 2022). Section 204(e)(2)

86 National Academies of Sciences, Engineering, and Medicine, An Approach to Evaluate the Effects of Concomitant

Prescribing of Opioids and Benzodiazepines on Veteran Deaths and Suicides, 2019.


Related Agencies, committee print, 116 th Cong., 2nd sess., 2020, p. 849. 88 See for example, S. 2991 (116th Congress).



requires GAO to submit a report on the results of the review and make the report publicly available no later than 90 days after completion of the review.

Section 204(c) requires the data compiled under subsections (a) and (b) to be separated and disaggregated by year so that such data can be analyzed across all data fields to potentially inform and update VA clinical practice guidelines.

Section 205: Comptroller General Report on Management by Department of

Veterans Affairs of Veterans at High Risk for Suicide

Background

Suicide is difficult to predict for many reasons—one reason being that there is no one cause of

suicide. A 2016 meta-analysis of national and international longitudinal studies examining suicide

risk among psychiatric patients concluded that “a statistically strong and reliable method to

usefully distinguish patients with a high-risk of suicide remains elusive.”89 However, recent

research suggests that data from health care records can be used to predict suicide risk, and such research was used in development of VHA’s REACH VET program.90

In addition, VHA launched a new, standardized suicide screening initiative in 2018 for all veterans receiving VHA care.91 The suicide risk screening was fully implemented in October

2019 and occurs in three phases, with the first phase comprising an annual initial screening.92

Veterans who receive positive screenings from the first phase or who are receiving mental health

care are administered the second phase, which includes six questions from the Columbia-Suicide

Severity Rating Scale (C-SSRS), an evidence-based screener used by both national and international institutions.93 The third and final phase is administered to veterans who receive a

positive screening from the second phase or who have demonstrated suicidal behavior. This third

phase, VA’s Comprehensive Suicide Risk Evaluation, is a more in-depth evaluation that assesses

warning signs and history of attempts, among other things. This final phase is intended to form a

mental health treatment plan specific to the needs of the veteran.94 Suicide prevention

89 Matthew Large, Muthusamy Kaneson, Nicholas Myles, et al., “Meta-Analysis of Longitudinal Cohort Studies of

Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time,”

PLoS ONE, vol. 11, no. 6 (June 10, 2016), p. https://doi.org/10.1371/journal.pone.0156322. 90 U.S. Congress, House Committee on Veterans’ Affairs, Testimony before the House Committee on Veteran’s Affairs,

Tragic Trends: Suicide Prevention Among Veterans, prepared by Shelli Avenevoli, Ph.D., 116 th Cong., 1st sess., April

29, 2019, p. 3.

91 Department of Veterans Affairs, “ VA sets standards in suicide risk assessment, offers support to community

providers,” January 2, 2019, https://blogs.va.gov/VAntage/55281/va-sets-standards-in-suicide-risk-assessment-offers-

support-to-community-providers/.

92 U.S. Government Accountability Office, VA Needs Accurate Data and Comprehensive Analyses to Better

Understand On-Campus Suicides, GAO-20-664, September 2020, p. 8, https://www.gao.gov/assets/710/709243.pdf. 93 National Suicide Prevention Lifeline, “Columbia-Suicide Severity Rating Scale (C-SSRS),”

https://suicidepreventionlifeline.org/wp-content/uploads/2016/09/Suicide-Risk-Assessment-C-SSRS-Lifeline-Version-

2014.pdf.

94 Department of Veterans Affairs, “ VA sets standards in suicide risk assessment, offers support to community

providers,” January 2, 2019, https://blogs.va.gov/VAntage/55281/va-sets-standards-in-suicide-risk-assessment-offers-

support-to-community-providers/.



coordinators (SPCs) coordinate the mental health care of at-risk veterans,95 and family and friends play an important role in supporting at-risk veterans.96

Provision

Section 205 requires GAO to conduct a study, no later than 18 months after enactment (i.e., April

17, 2022), on VA’s efforts to manage veterans at high risk for suicide. The report is required to include, among other things (1) a description of how VA identifies patients at high risk for

suicide; (2) a description of how VA intervenes when a patient is identified as high risk; (3) a

description of how VA monitors patients who have been identified as high risk; (4) a review of

staffing levels of SPCs across VHA; (5) a review of the resources and programming offered to

family members and friends of veterans with a mental health condition; and (6) any other areas GAO considers appropriate.

Title III: Programs, Studies, and Guidelines on Mental Health

An understanding of mental health disorders is strengthened through research; likewise, treatment

informed by such research is evolving. This title includes provisions to require research on certain

suicide risk factors among veterans; to implement an initiative to identify and validate brain and

mental health biomarkers—measurable characteristics of body functions (e.g., blood pressure)—

among veterans; to provide VA with additional authority to use data collected from electronic

health systems to analyze mental health outcomes; and to establish and update VA and DOD mental health and suicide treatment resources.

Section 301: Study on Connection Between Living at High Altitude and

Suicide Risk Factors Among Veterans

Background

Both international and domestic studies have found that individuals who live at higher altitudes

are at increased risk for suicide. In one study conducted using U.S. data, this correlation held even

when accounting for other factors, such as gender, poverty, access to health care, and population

density.97 Furthermore, the correlation between altitude and suicide was stronger among veterans

than nonveterans. Among veterans, the correlation was not significant among veterans aged 18-34, but it was significant in all other age groups above age 35, with the greatest correlation among veterans who were older than 75.98

Hypoxia is a condition that causes decreased oxygenation in the body tissues. One study found that chronic hypoxic markers—living at high altitude, smoking, and chronic obstructive

95 Department of Veterans Affairs, Veterans Health Administration, “Uniform Mental Health Services in VA M edical

Centers and Clinics,” VHA Handbook 1160.01, amended November 16, 2015. 96 Department of Veterans Affairs, “National Strategy for Preventing Veteran Suicide, 2018 -2028,” p. 28,

https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-


97 Hana Sabic, Brent Kious, Danielle Boxer, et al., “Effect of Altitude on Veteran Suicide Rates,” High Altitude

Medicine & Biology, vol. 20, no. 2 (June 1, 2019), pp. 171-177.

98 Hana Sabic, Brent Kious, and Danielle Boxer, et al., “Effect of Altitude on Veteran Suicide Rates,” High Altitude

Medicine & Biology, pp. 171-177.



pulmonary disease (COPD)—may increase suicide risk in veterans.99 As noted by VA, although

chronic hypoxia appears to play a role in the correlation between altitude and suicide, more

research is needed to understand the role that demographic, social, and environmental factors may

play. Understanding if and how altitude contributes to suicide could help to determine appropriate prevention and treatment options.100

Provision

Section 301 requires the Secretary, no later than 180 days after enactment (i.e., April 15, 2021), to

conduct a study on the connection between living at high altitude and the risk of developing

depression or dying by suicide among veterans on an individual level (rather than at the state or

county level). The study is to be completed no later than three years after it commences, and, the

Secretary shall submit a report on the findings of the study to SVAC and HVAC no later than 150 days after its completion.

Section 301(e) requires the Secretary to conduct a follow-up study if the study conducted under this section shows high altitude to be a risk factor for developing depression or dying by suicide.

The follow-up study shall focus on likely biological mechanisms underlying this association, and

the most effective treatment or intervention for reducing risk of adverse outcomes associated with

living at high altitude. No later than 150 days after completing a follow-up study, the Secretary would be required to submit a report on the results of the study to SVAC and HVAC.

Sections 302, 303, and 304: Establishment by Department of Veterans Affairs

and Department of Defense of a Clinical Provider Treatment Toolkit and

Accompanying Training Materials for Comorbidities; Update of Clinical

Practice Guidelines for Assessment and Management of Patients at Risk for

Suicide; and Establishment by Department of Veteran Affairs and Department

of Defense of Clinical Practice Guidelines for the Treatment of Serious Mental

Illness

Background

VA and DOD often collaborate to jointly develop and publish selected clinical practice guidelines

(CPGs) to help health care providers deliver evidenced-based treatment for certain health issues

prevalent in military and veteran populations.101 Although VA and DOD do not require their health care providers to use the CPGs, the documents typically provide insight on “best practices”

when developing patient treatment plans.102 Current VA/DOD CPGs include treatment pathways

99 Natalie B. Riblet, Daniel J. Gottlieb, Bradley V. Watts, et al., “Hypoxia-related risk factors for death by suicide in a

national clinical sample,” Psychiatry Res., vol. 273 (March 2019), pp. 247-251. 100 Office of Mental Health and Suicide Prevention, Veterans Health Administration, Understanding the Relationship

Between Altitude and Suicide Risk, U.S. Department of Veterans Affairs, January 31, 2020,

https://www.mentalhealth.va.gov/suicide_prevention/docs/Literature_Review_FSTP_Altitude_CLEARED_508_1-31-

20.pdf.

101 The National Academy of Medicine (formerly the Institute of Medicine) describes clinical practice guidelines

(CPGs) as “statements that include recommendations intended to optimize patient care. They are informed by a

systematic review of evidence and an assessment of the benefits and harms of alternative care options.” For more on

CPGs, see Institute of Medicine, Clinical Practice Guidelines We Can Trust, Washington, DC, 2011, pp. 25-26,

https://www.nap.edu/catalog/13058/clinical-practice-guidelines-we-can-trust. 102 Department of Veterans Affairs, “VA/DoD Clinical Practice Guidelines,” accessed December 15, 2020,



for pain management, women’s health, trauma rehabilitation, and certain chronic diseases or

conditions (e.g., hypertension, dyslipidemia, and obstructive sleep apnea).103 Four VA/DOD CPGs are specific to mental health:

assessment and management of patients at risk for suicide,

major depressive disorder,

posttraumatic stress disorder (PTSD), and

substance use disorder.104

The VA/DOD Health Executive Committee’s Evidence Based Practice Work Group oversees the collaboration process used to develop, adopt, or update VA/DOD CPGs.105

Provisions

Section 302 directs the Secretary to develop a “clinical provider treatment toolkit and

accompanying training materials” for (1) comorbid mental health conditions, (2) comorbid mental health and substance use disorders, and (3) comorbid mental health and chronic pain. The

Secretary is required to consult with the Secretary of Defense in developing the toolkit, which

would include elements similar to those in existing VA/DOD CPGs. The toolkit is to include additional guidance on treating patients with

PTSD and additional mental health, substance use, or chronic pain issues;

mental health conditions (e.g., anxiety, depression, bipolar disorder) and

substance use or chronic pain issues; and

traumatic brain injury (TBI) and mental health, substance use, or chronic pain

issues.

The Secretary is required to develop this toolkit no later than two years from the date of enactment (i.e., October 17, 2022).

Section 303 requires VA and DOD to add new or enhanced guidance in the next published update

of the VA/DOD CPG on Assessment and Management of Patients at Risk for Suicide. The revised

CPG is to include guidance on (1) gender-specific risk factors, prevention, and treatments for

suicide and suicidal ideation; (2) the efficacy of alternative therapies (e.g., yoga, meditation, art therapy, equine therapy, music therapy); and (3) the findings from the COVER Commission.106

https://www.healthquality.va.gov; and Department of Defense (DOD) Psychological Health Center of Excellence,

“VA/DoD Clinical Practice Guidelines and Clinical Support Tools,” accessed December 18, 2020,

https://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools.

103 Department of Veterans Affairs, “VA/DoD Clinical Practice Guidelines,” and Department of Defense Psychological

Health Center of Excellence, “VA/DoD Clinical Practice Guidelines and Clinical Support Tools.” 104 Department of Veterans Affairs, “VA/DoD Clinical Practice Guidelines,” and Department of Defense Psychological

Health Center of Excellence, “VA/DoD Clinical Practice Guidelines and Clinical Support Tools.”

105 The Health Executive Committee (HEC) is a joint VA/DOD entity responsible for “sharing and collaboration efforts

to ensure the effective and efficient use of health services and resources.” The HEC also oversees numerous work

groups and “business lines,” including the Evidence Based Practice Work Group (EBPWG). For more on the HEC, see

https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/DoD-VA-

Sharing-Initiatives/Joint-Oversight/HEC. For more on the EBPWG, see https://www.healthquality.va.gov/documents/

EvidenceBasedPracticeWGCharter123020161.pdf. For more on the CPG development process, see

https://www.qmo.amedd.army.mil/general_documents/GuidelinesforGuidelines.pdf. 106 Section 931 of the Jason Simcakoski Memorial and Promise Act, as incorporated in the Comprehensive Addiction

and Recovery Act of 2016 (P.L. 114-198), directed the establishment of the COVER Commission to “examine the



Section 304 directs VA, DOD, and the Department of Health and Human Services (HHS) to

establish a Serious Mental Health Illness Work Group composed of representatives from federal

entities, including VA’s Health Services Research and Development office, the National Institute

of Mental Health, and the Indian Health Service; nonfederal entities (e.g., academic institutions

specializing in mental health treatments); and other organizations with relevant mental health

expertise. No later than two years after enactment (i.e., October 17, 2022), the Secretary and the work group are required to develop new CPGs on the following mental health conditions:

schizophrenia;

schizoaffective disorder;

persistent mood disorder, including bipolar disorders; and

other mental health issues that result in “serious functional impairment that

substantially interferes with major life activities.”

In addition, the Secretary is required to consult with the Secretary of Defense and the HHS

Secretary no later than two years from enactment (i.e., October 17, 2022), to assess the VA/DOD CPG on Management of Major Depressive Disorder for any necessary updates.107

Section 305: Precision Medicine Initiative of Department of Veterans Affairs to

Identify and Validate Brain and Mental Health Biomarkers

Background

Precision medicine is defined as “an approach to disease treatment and prevention that seeks to

maximize effectiveness by taking into account individual variability in genes, environment, and

lifestyle.”108 In January 2015, President Obama announced the launch of the Precision Medicine

Initiative (PMI); this effort was codified by the 21st Century Cures Act (P.L. 114-255) in December 2016.109 Since 2015, the PMI has been undertaken and led by the National Institutes of

Health (NIH), in collaboration with other federal agencies, primarily through the All of Us

Research Program,110 a million-person national research cohort program. The program has

focused intensively on areas such as governance, recruitment strategies, privacy and security of data, diversity, and data access policies.

Precision medicine research efforts rely on the collection and storage of large amounts of health

and other data; therefore, privacy and security of, and access to, this data may be a concern in the context of this type of research. Specifically, the All of Us Research Program is carried out

consistent with applicable requirements in the HIPAA Privacy and Security Rules ,111 which

evidence-based therapy treatment model used by the Secretary for treating mental health conditions of veterans and the

potential benefits of incorporating complementary and integrative health treatments in non -Department facilit ies.”

107 For more on the VA/DOD CPG on the Management of Major Depressive Disorder, see

https://www.healthquality.va.gov/guidelines/MH/mdd/.

108 Precision Medicine Initiative (PMI) Working Group Report to the Advisory Committee to the Director, NIH, “The

Precision Medicine Initiative Cohort Program – Building a Research Foundation for 21st Century Medicine,”

September 17, 2015, p. 6, https://www.nih.gov/sites/default/files/research-training/initiatives/pmi/pmi-working-group-

report-20150917-2.pdf. 109 PHSA §498E; 42 U.S.C. §289g-5.

110 For more information, see https://allofus.nih.gov/.

111 45 C.F.R. Part 164, Subparts C and E.



govern the use and disclosure of protected health information (PHI), as well as the Common Rule,112 which governs human research subject protection in federally funded research.

Provision

Section 305 requires the Secretary, no later than 18 months after enactment (i.e., April 17, 2022),

to develop and implement an initiative to identify brain and mental health biomarkers 113 among veterans for specified conditions (e.g., depression, anxiety, PTSD, among others). The initiative

must be modeled on NIH’s All of Us Precision Medicine Initiative and coordinated with the VA’s

Million Veterans Program. Data collected under this initiative must be standardized, as specified,

and the Secretary is required to develop robust data privacy and security measures consistent with

the Privacy Act of 1974,114 as well as the HIPAA Rules,115 with access to the data required to be

similarly governed. The Secretary is required to make de-identified data, as defined, available as specified to both federal agencies and nongovernmental entities for research purposes.

Section 306: Statistical Analyses and Data Evaluation by Department of

Veterans Affairs

Background

This section was derived from the VA Data Analytics and Technology Assistance Act, introduced

in the 116th Congress (H.R. 8148). In a congressional hearing on this legislation, the bill’s

sponsor, Representative Conor Lamb, explained that the intent of the language is to provide the

Secretary with authority to use artificial intelligence and other means of examining data to

determine if there is a link between data collected by VA’s electronic health records system or other data and mental health outcomes.116

Provision

This section adds a new section 119 to Chapter 1 of title 38 of U.S.C., which authorizes the

Secretary to enter into a contract or other agreement with an academic institution or other

qualified entity, as determined by the Secretary, to carry out statistical analyses and data evaluation as required of the Secretary under current law.

112 45 C.F.R. Part 46. 113 According to the Food and Drug Administration, a biomarker is “a defined characteristic that is measured as an

indicator of normal biological processes, pathogenic processes, or responses to an exposure or intervention, including

therapeutic interventions.” See https://www.fda.gov/media/99221/download.

114 5 U.S.C. §552a. 115 Defined in the section as “rules promulgated pursuant to the Health Insurance Portability and Accountability Act of

1996 (parts 160, 162, and 164 of tit le 45, Code of Federal Regulations, or successor regulations)”; 45 C.F.R. Parts 160,

162, and 164.

116 U.S. Congress, House Committee on Veterans’ Affairs, Full Committee Legislative Hearing, 116th Cong., 2nd sess.,

September 10, 2020.



Title IV: Oversight of Mental Health Care and Related Services

VA health care is considered a “high-risk area” by the GAO.117 Recent GAO reports suggest that certain aspects of VHA’s suicide prevention efforts could be improved.118 This title includes

provisions that require GAO to conduct oversight of VA’s mental health and suicide prevention

services, and to provide additional reporting to Congress on select suicide prevention and mental health programs within VHA and those jointly administered by VA and DOD.

Section 401: Study on Effectiveness of Suicide Prevention and Mental Health

Outreach of Department of Veterans Affairs

Background

As specified by VA in its national strategy to prevent veteran suicide, public awareness and other

outreach efforts are a key component of necessary prevention efforts.119 Developing evidence-based consistent messaging requires many steps, including conducting research to ensure that the

target audience understands both the problem and desired behavior to address it. Research

methods can include literature reviews, surveys, and focus groups.120 These methods can be

useful for evaluating the effectiveness of public awareness campaigns once they have been disseminated.

Although VA has conducted its own evaluations of suicide prevention activities,121 few

independent evaluations have examined VHA’s suicide prevention outreach materials and

campaigns. Congress has previously required VA to enter into third-party contracts to evaluate VHA’s mental health and suicide prevention programs, but these evaluations are not specific to mental health and suicide prevention outreach conducted by VHA.122

Provision

Section 401(a) requires the Secretary, no later than 180 days after enactment (i.e., April 15, 2021),

to enter into an agreement with an entity outside the federal government to evaluate suicide prevention and mental health outreach materials and campaigns prepared and conducted by VA.

Section 401(b) requires the Secretary to convene focus groups as part of the evaluation required

under subsection (a). At minimum, the Secretary is required to convene at least eight different

focus groups. Such focus groups must meet specified requirements in timing, number of

117 GAO, “Managing Risks and Improving VA Health Care,” https://www.gao.gov/highrisk/managing-risks-and-

improving-va-health-care.

118 See, for example, U.S. Government Accountability Office, VA Health Care: Improvements Needed in Suicide

Prevention Media Outreach Campaign Oversight and Evaluation , GAO-19-66, November 15, 2018,

https://www.gao.gov/assets/700/695485.pdf, and U.S. Government Accountability Office, VA Needs Accurate Data

and Comprehensive Analyses to Better Understand On-Campus Suicides, GAO-20-664, September 2020, p. 6,

https://www.gao.gov/assets/710/709243.pdf.

119 Department of Veterans Affairs, “National Strategy for Preventing Veteran Suicide, 2018 -2028,” p. 9, https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-National-


120 Linda Langford, David Litts, and Jane L. Pearson, “Using Science to Improve Communications About Suicide

Among Military and Veteran Populations: Looking for a Few Good Messages,” American Journal of Public Health ,

vol. 103 (January 2013), p. 33.

121 Department of Veterans Affairs, Office of Inspector General, Evaluation of Suicide Prevention Programs in

Veterans Health Administration Facilities, May 18, 2017, https://www.va.gov/oig/pubs/VAOIG-16-03808-215.pdf. 122 38 U.S.C. §1709B, as added by Section 2 of the Clay Hunt SAV Act (P.L. 114-2).



participants, and representation of participants (e.g., minority veterans). Section 401(c) requires

the Secretary, no later than 90 days after the last focus group meeting under subsection (b), to

submit a report to SVAC and HVAC on the focus group findings. The report must include, among

other things, recommendations for future suicide prevention and mental health materials and

campaigns, and a description of any dissenting or opposing viewpoints raised by participants in the focus group.

Section 401(d) requires the Secretary, no later than one year after the last focus group meeting

under subsection (b), to complete a survey on the effectiveness of mental health and suicide prevention materials and campaigns. The survey must be informed by the focus group findings

and be representative of the veteran population, among other things. Section 401(e) requires that,

for each contract regarding the development of suicide prevention and mental health materials

and campaigns, the contractor must include representative veteran focus groups as part of

effectiveness assessments. Per Section 401(e)(2), such contracts must include a requirement that

subcontractors have experience creating influential media campaigns targeting individuals aged 18 to 34. Not more than 2% of VHA OMHSP’s contractor budget for suicide prevention and

mental health media outreach can be allocated to these subcontractors. Section 401(f) exempts

information collection required under this section from the Paperwork Reduction Act (PRA) of 1995.123

Section 402: Oversight of Mental Health and Suicide Prevention Media

Outreach Conducted by Department of Veterans Affairs

Background

In response to a 2018 request from then HVAC ranking member Representative Tim Walz, GAO

conducted a review of VHA’s suicide prevention media outreach activities and related oversight.124 Specifically, the report examined the activities conducted by VHA for its suicide

prevention media outreach campaign, and to what extent VHA evaluates the effectiveness of

those activities. GAO examined VHA’s contract to develop suicide prevention outreach from

FY2013 to FY2016 and its contract to develop suicide prevention and mental health outreach from FY2017 to FY2018.

GAO found that VHA’s suicide prevention media outreach activities declined in FY2017 and

FY2018, and that, accordingly, VHA had spent significantly less than its obligated suicide

prevention paid media budget. Media outreach activities include the development of social media content, public service announcements (PSAs), paid media (e.g., VHA pays a fee to more broadly

disseminate social media posts), and Suicide Prevention Month activities. According to VHA, this

reduction was due to leadership turnover and reorganization of the offices responsible for suicide

prevention activities. GAO noted that by not assigning key leadership responsibilities and direct

lines of reporting on progress, VHA was not able to effectively implement its suicide prevention media outreach activities and provide proper oversight of progress, including obligations spent

and effectiveness of the campaign. To address these issues, GAO provided specific

recommendations, including, among others, a delineation of roles and responsibilities, and

123 P.L. 104-13. The PRA requires, among other things, that agencies obtain Office of Management and Budget (OMB)

approval before requesting most information from the public.

124 U.S. Government Accountability Office, VA Health Care: Improvements Needed in Suicide Prevention Media

Outreach Campaign Oversight and Evaluation , GAO-19-66, November 15, 2018, https://www.gao.gov/assets/700/

695485.pdf.



establishing targets for its metrics (e.g., goals for how many individuals VHA wishes to view its outreach content) to improve evaluation efforts.125

Provision

Section 402(a) codifies the aforementioned GAO recommendations. Namely, it requires the

Secretary to establish goals for VA mental health and suicide prevention media outreach campaigns, including the establishment and tracking of targets, metrics, and action plans to

describe and assess campaigns. In establishing these goals, the Secretary is required to consult

with mental health and suicide prevention experts, as well as relevant stakeholders and other

persons determined appropriate by the Secretary. These goals are required to be measured by

metrics specific to media types (e.g., engagement rate relating to social media or response rate

relating to email), and these metrics must be periodically updated as more accurate metrics become available. Section 402(a)(5) requires the Secretary, no later than 180 days after enactment

(i.e., April 15, 2021), to submit an initial report to SVAC and HVAC on the goals—including

metrics and targets for such metrics—established for the VA mental health suicide prevention

media outreach campaigns. Section 402(a)(6) requires the Secretary, no later than one year after

the report submitted under paragraph (5), to submit a report, and annually thereafter, to SVAC and HVAC on the progress of VA meeting the established goals and action to be taken by VA to modify goals and targets not being met.

Section 402(b) requires the Secretary, no later than 180 days after enactment (i.e., April 15, 2021) and semiannually thereafter, to submit a report to the MILCON-VA, SVAC, and HVAC on OMHSP obligations and expenditures during the period covered by the report.

Section 403: Comptroller General Management Review of Mental Health and

Suicide Prevention Services of Department of Veterans Affairs

Background

Prior to 2017, VHA suicide prevention and mental health activities were organized in different

offices. In May 2017, VHA’s OMHSP was established.126 This reorganization was intended to

improve efficiency, as well as to encourage better communication and collaboration of related

VHA operations. VHA’s OMHSP issues policy and implementation guidance, and it provides oversight and management of VHA mental health and suicide prevention initiatives and

services.127 Such initiatives include coordination of suicide prevention efforts with DOD and

oversight of the VCL, among other things. Some VAMCs and outpatient clinics offer a Nurse

Advice Line—similar to the VCL—which allows veteran patients and their caregivers to speak at any time with a registered nurse about a health issue, including a mental health-related concern.128

125 U.S. Government Accountability Office, VA Health Care: Improvements Needed in Suicide Prevention Media

Outreach Campaign Oversight and Evaluation , GAO-19-66, November 15, 2018, p. 21, https://www.gao.gov/assets/

700/695485.pdf. 126 U.S. Government Accountability Office, VA Needs Accurate Data and Comprehensive Analyses to Better

Understand On-Campus Suicides, GAO-20-664, September 2020, p. 6, https://www.gao.gov/assets/710/709243.pdf.



fy2021VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf . 128 Department of Veterans Affairs, “VA VISN 12 Nurse Advice Line (Telephone Care Service),”

https://www.madison.va.gov/documents/Telephone-Care.pdf.



Provision

Section 403 requires GAO to conduct a study, no later than three years after enactment (i.e.,

October 17, 2023), on the management of mental health and suicide prevention services provided

by VA. The management review is required to include, among other things (1) an assessment of

OMHSP infrastructure, as well as infrastructure of suicide prevention efforts not operated by OMHSP; (2) a description of OMHSP management, organization, staffing levels, and operations

(including strategic planning); (3) an assessment of suicide prevention practices and initiatives

available through VA and community partnerships; (4) an assessment of the Nurse Advice Line

pilot program; (5) an assessment of VA/DOD coordination of suicide prevention efforts; and (6) any other areas GAO considers appropriate.

Section 404: Comptroller General Report on Efforts of Department of Veterans

Affairs to Integrate Mental Health Care into Primary Care Clinics

Background

Integrated behavioral health occurs when a team of providers, including physicians, behavioral

health providers, and other health care providers, work together to address a patient’s physical and mental health/substance use needs.129 Although different models of behavioral health

integration exist, some models emphasize integrating behavioral health services into primary

care. In general, patients with behavioral health concerns interact more frequently with primary

care, and they may not follow through to the behavioral health specialty care sector if referred from primary care.130

VHA first began primary care-mental health integration (PC-MHI) in 2007, and by 2008, it

required all VAMCs and very large community-based outpatient clinics (CBOCs; those serving

more than 10,000 patients a year) to have integrated mental health services in primary care clinics on a full-time basis.131 CBOCs serving 10,000 patients or less must also have varying levels of

integrated mental health services. VHA’s PC-MHI comprises two categories: (1) co-located,

collaborative care (CCC) and (2) care management. CCC provides behavioral health services in

short duration as part of routine primary care service, and is not necessarily specific to patients

with behavioral health disorders. CCC providers—mental health staff, including social workers, psychiatric nurses, psychiatrists, psychologists—are embedded in Patient Aligned Care Teams

(PACTs), a team of health care providers that provides comprehensive primary care in partnership

with the patient.132 Care management is provided in consultation with the PACTs, but is largely

administered by telephone. Care management services are structured toward those with more

severe behavioral health concerns and includes systematic monitoring of symptoms and referral to specialty behavioral health care if needed.133 Once a patient starts receiving services in

129 Health Resources and Services Administration (HRSA), “Integrated Behavioral Health Resource Library,”

https://www.hrsa.gov/behavioral-health/library.

130 The Commonwealth Fund, “In Focus: Integrating Behavioral Health and Primary Care,” August 28, 2014, https://www.commonwealthfund.org/publications/newsletter-article/2014/aug/focus-integrating-behavioral-health-and-

primary-care.

131 Department of Veterans Affairs, Veterans Health Administration, “Uniform Mental Health Services in VA Medical

Centers and Clinics,” VHA Handbook 1160.01, p. 34, amended November 16, 2015.

132 Department of Veterans Affairs, Veterans Health Administration, “Patient Aligned Care Team (PACT) Handbook,”

VHA Handbook 1101.10(1), p. 4, amended May 26, 2017. 133 Margaret Dundon, Katherine Dollar, Larry J. Lantinga, et al., Primary Care-Mental Health Integration Co-Located,



specialty behavioral health care, a behavioral health provider in primary care will no longer provide care, except under very specific circumstances.134

The Veterans Community Care Program (VCCP) was launched in June 2019, as established by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018

(VA MISSION Act; P.L. 115-182). Under this program, eligible veterans receive care in the

community (through non-VA providers) when specific eligibility criteria are met.135 To implement

VCCP, VA entered into Community Care Network (CCN) contracts with Optum Public Sector Solutions, Inc., and TriWest Healthcare Alliance Corporation.

Prior to the implementation of VCCP, researchers from the RAND Corporation evaluated the capacity of providers in New York to deliver care to veterans, finding that

only 20 percent of New York–licensed health care professionals reported routinely

screening their patients for a military or veteran affiliation, with significant differences across provider types and by region. As a result, many providers are missing an opportunity to begin a conversation about how having a military history and background might have

contributed to their veteran patients’ current medical condition.136

Furthermore, RAND researchers reported that “private providers were less prepared than VA

providers to deliver high-quality mental health care to veterans.”137 Taking these concerns into

consideration, the VA MISSION Act included Section 123, which requires VA to implement a

program to provide continuing medical education material and training to non-VA medical

providers.138 The department established the VHA Training Finder Real-time Affiliate-Integrated

Network (VHA-TRAIN) and provides courses and training programs such as Military Culture: Core Competencies for Health Care Professionals Stressors and Resources, Military Culture:

Core Competencies for Health Care Professionals Self-Assessment and Introduction to Military Ethos, and Addressing Traumatic Guilt in PTSD Treatment, among others.139

Provision

Section 404(a) requires GAO to submit an initial report, no later than two years after enactment (i.e., October 17, 2022), on the integration of mental health care into VHA primary care clinics.

The report is required to include, among other things (1) an assessment of efforts to integrate

mental health care into VHA primary care clinics, including how effective these efforts have been

and how health care is affected by integration; (2) a description of how care is coordinated under

Collaborative Care: An Operations Manual, Center for Integrated Healthcare, June 2011, p. 5,

https://www.mentalhealth.va.gov/coe/cih-visn2/Documents/Clinical/Operations_Policies_Procedures/MH-

IPC_CCC_Operations_Manual_Version_2_1.pdf. 134 Margaret Dundon, Katherine Dollar, Larry J. Lantinga, et al., Primary Care-Mental Health Integration Co-Located,

Collaborative Care: An Operations Manual, Center for Integrated Healthcare, June 2011, p. 20.

135 For more information, see CRS Report R42747, Health Care for Veterans: Answers to Frequently Asked Questions;

38 C.F.R. §17.4010, and 38 C.F.R. §17.4040.

136 Terri Tanielian et al., Ready or Not? Assessing the Capacity of New York State Health Care Providers to Meet the

Needs of Veterans, RAND Corporation, Santa Monica, CA, 2018, https://www.rand.org/pubs/research_reports/

RR2298.html. 137 RAND Corporation, Improving the Quality of Mental Health Care for Veterans: Lessons from RAND Research ,

2019, https://www.rand.org/pubs/research_briefs/RB10087.html.

138 CRS Report R45390, VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018

(VA MISSION Act; P.L.115-182). 139 Department of Veterans Affairs, Report on Section 123 of the VA Maintaining Internal Systems and Strengthening

Integrated Outside Networks (MISSION) Act of 2018: Continuing Medical Education for Non -Department Medical

Professionals, June 2020, p. 6.



specified circumstances; (3) an assessment of how integration is implemented at different types of

VHA facilities (e.g., VAMCs, CBOCs); (4) recommendations on how integration can be better implemented; and (5) any other areas GAO considers appropriate.

Section 404(b) requires GAO to submit, no later than two years after submission of the report

required under section 404(a), a report on the integration of community-based mental health care

into VHA. The report is required to include, among other things, (1) an assessment of VA’s

efforts to integrate community-based mental health care into VHA, including effectiveness of

such efforts and how health care of veterans is affected by integration; (2) a description of how care is coordinated between community-based mental health care providers and VHA; (3) an

assessment of any disparities in coordination of community-based mental health care integration

into VHA by location and type of facility; (4) an assessment of military cultural competency of

community-based mental health care providers; (5) recommendations on how community-based

health care integration into VHA can be better implemented; and (6) any other areas GAO

considers appropriate. Section 404(b)(3) defines “community-based mental health care” as mental health care paid for by VA but provided at a non-VHA health care site, including care provided under the VCCP.

Section 405: Joint Mental Health Programs by Department of Veterans Affairs

and Department of Defense

Background

Congress has a long history of funding and authorizing numerous DOD and VA mental health

programs and services that support servicemembers, veterans, and their families. DOD and VA

deliver mental health services in wide ranges of clinical and nonclinical settings (e.g., military

treatment facilities, military units, VA hospitals and clinics, community-based programs, and virtual modalities). Both departments administer a number of mental health programs, typically in

accordance with various VA and DOD strategy documents on interagency collaboration and

resource sharing (e.g., the Joint Strategic Plan or the Integrated Mental Health Strategy).140 These

programs aim to prevent, evaluate, diagnose, treat, or discover new mental health issues and expand new science on broad or condition-specific issues.

In 2010, DOD established the National Intrepid Center of Excellence (NICoE) to “advance

treatment, research, and education in the areas of TBI and neurological and psychological

health.”141 NICoE coordinates with the VA’s Polytrauma Centers to synchronize specialized outpatient treatments and emerging rehabilitative therapies for servicemembers and veterans

diagnosed with TBI and other mental health conditions.142 To extend NICoE’s reach, DOD

140 Section 8111 of T itle 38, U.S. Code, requires DOD and VA to coordinate and share certain health care resources.

The statute also requires both departments to develop a Joint Strategic Plan (JSP) to “shape, focus, and prioritize the coordination and sharing efforts among appropriate elements of the two Departments.” For more on the JSP, see

https://prhome.defense.gov/Portals/52/Documents/VA-DoD%20FY%202019-

2021%20JSP%20(signed%20March%2018%202019).pdf . In 2011, DOD and VA developed an Integrated Mental

Health Strategy (IMHS) to implement a “coordinated public health model to improve the access, quality, effectiveness,

and efficiency of mental health services” for servicemembers, veterans, and their families. For more on the IMHS, see

https://www.mentalhealth.va.gov/docs/VA-DoD_IMHS_Action_Summaries_040814.pdf.

141 Department of Defense, National Intrepid Center of Excellence Satellite Strategic Basing , June 2020, p. 3,

https://go.usa.gov/xAgDg. For more information on NICoE, see https://walterreed.tricare.mil/Health-Services/

Specialty-Care/National-Intrepid-Center-of-Excellence-NICoE. 142 Department of Defense, National Intrepid Center of Excellence Satellite Strategic Basing , June 2020, pp. 3-5. VA

Polytrauma Centers are part of an “integrated network of specialized rehabilitative programs” that serves



established satellite sites, known as Intrepid Spirit Centers, offering similar TBI treatment and

therapy services. DOD maintains eight Intrepid Spirit Centers in the United States, with two

additional locations planned.143 In 2019, the Senate Appropriations Committee report

accompanying the DOD Appropriations Act, 2020, directed DOD and VA to describe the “value

and merit of establishing a Joint NICoE Intrepid Spirit Center that serves both active duty and

veteran populations for their mutual benefit and growth in treatment and care.”144 In the subsequent report to Congress, issued in June 2020, DOD and VA asserted that there was “neither

value nor merit that supports establishment of a joint NICoE Intrepid Spirit Center at this time.”145

Provision

Section 405 establishes two reporting requirements for DOD and VA. The first reporting requirement is the submission of an annual report to Congress, beginning in October 2021, on

mental health programs individually and jointly administered by each department. The report is to

be submitted to the House and Senate Armed Services, SVAC, and HVAC, and to include a description of various VA and DOD mental health or related programs, such as

a transition assistance program;

clinical and nonclinical mental health initiatives;

certain quality-of-life programs (e.g., financial literacy, housing assistance, and

employee assistance programs);

mental health research on PTSD, depression, anxiety, bipolar disorder, TBI,

suicide or suicidal ideation; and

other issues or conditions as the Secretary or the Secretary of Defense consider

necessary.

The report is to also include recommendations to “improve the effectiveness” of such programs and on “novel joint programming” to improve the mental health of servicemembers and veterans.

The second reporting requirement is an evaluation and report to Congress on DOD and VA

collaboration on PTSD and TBI care, research, and education. The evaluation is to include an

analysis of alternatives and recommendations on the establishment of a joint DOD and VA

Intrepid Spirit Center. The report on DOD and VA’s findings is to be submitted to the House and Senate Committees on Armed Services, SVAC, and HVAC no later than 270 days after enactment (i.e., July 14, 2021).

Title V: Improvement of Mental Health Medical Workforce

The Health Resources and Services Administration (HRSA) projects that national demand for

physician services, including mental health services, will exceed supply by 2025. Further, HRSA

has reported that these projected shortages will be exacerbated in rural areas, a situation that

poses a particular challenge for VHA because at least 26% of its VAMCs are located in rural

servicemembers and veterans with combat - or civilian-related TBI and polytrauma. For more on VA Polytrauma

Centers, see https://www.polytrauma.va.gov. 143 Department of Defense, National Intrepid Center of Excellence Satellite Strategic Basing , June 2020, p. 3.

144 S.Rept. 116-103, p. 241.

145 Department of Defense, National Intrepid Center of Excellence Satellite Strategic Basing , June 2020, p. 6.



areas.146 This title includes provisions that address VHA mental health provider staffing; authorize

a scholarship program for readjustment counselors at Vet Centers; and require additional reporting and oversight on Vet Centers and other VHA suicide prevention services.

Section 501: Staffing Improvement Plan for Mental Health Providers of


Background

As of April 2020, VHA recommended that all VAMCs have an overall staffing level of at least

1.22 full time equivalent (FTE) psychiatrists and 7.72 FTE outpatient clinical mental health staff

for every 1,000 mental health patients.147 However, difficulties with recruitment, retention, and

lengthy hiring procedures have contributed to vacancies throughout the department. As of May 2019, HVAC reported that the current rate of vacancies in VHA mental health provider staffing

was 10%.148 According to NASEM, these vacancies vary by profession (e.g., psychiatrist,

psychologist) and by VISN.149 In particular, psychiatry was the top-ranked clinical occupation

determined to be in shortage by VHA facilities in FY2020.150 To address these concerns, VHA has

implemented a number of mechanisms to assist with recruitment and the retention of mental health providers.151

Section 201 of the Veteran Benefits, Health Care, and Information Act of 2006 (P.L. 109-461)

first authorized licensed professional mental health counselors (LPMHCs) and marriage and family therapists (MFTs) as mental health professionals that could be hired by VHA.152 Further, in

2012, VA began a mental health education expansion (MHEE) program to assist in recruitment

and hiring of VA-trained mental health providers. Through this program, four new professions

were allotted VA training opportunities, including internships for LPMHCs and MFTs.153

However, these two occupations did not have an associated occupational series, a classification standard issued by the U.S. Office of Personnel Management (OPM) for federal hiring purposes.

In FY2019 appropriations report language, Congress encouraged VA to work with OPM to

develop the occupational series. In addition, Congress directed VA to develop a staffing plan for LPMHCs and MFTs to fill open positions and address any shortages.154

146 U.S. Government Accountability Office, Veterans Health Administration: Better Data and Evaluation Could Help

Improve Physician Staffing, Recruitment, and Retention Strategies, GAO-18-124, October 2017, p. 6,

https://www.gao.gov/assets/690/687853.pdf.

147 Department of Veterans Affairs, Veterans Health Administration , “Productivity and Staffing in Clinical Encounters

for Mental Health Providers,” VHA Directive 1161, p. A-3, April 28, 2020.

148 H.Rept. 116-70. This statistic defined mental health provider staffing as including psychiatrists, psychologists, and

social workers. 149 National Academies of Sciences, Engineering, and Medicine, Evaluation of the Department of Veterans Affairs

Mental Health Services, Washington, DC, January 31, 2018, p. 176, https://www.ncbi.nlm.nih.gov/books/NBK499503/

pdf/Bookshelf_NBK499503.pdf.

150 Department of Veterans Affairs, Office of Inspector General, OIG Determination of Veterans Health

Administration’s Occupational Staffing Shortages Fiscal Year 2020 , Department of Veterans Affairs, September 23,

2020, p. 7, https://www.va.gov/oig/pubs/VAOIG-20-01249-259.pdf. 151 For more information, see National Academies of Sciences, Engineering, and Medicine, Evaluation of the

Department of Veterans Affairs Mental Health Services, 2018, p. 180.

152 38 U.S.C. §§7401-7402.

153 National Academies of Sciences, Engineering, and Medicine, Evaluation of the Department of Veterans Affairs

Mental Health Services, 2018, p. 180. 154 S.Rept. 115-269.



Provision

Section 501(a)(1) requires, no later than one year after enactment (i.e., October 17, 2021), VA to

submit to SVAC and HVAC a plan to address mental health provider staffing within VA. The plan

is required to include (1) an estimate of the number of mental health provider positions that need

to be filled, (2) steps VA will take to address mental health staffing, (3) a description of region-specific hiring incentives, (4) a description of local retention or engagement incentives to be used

by VISN directors, and (5) recommendations for legislative or administrative action to address

mental health staffing. Section 501(a)(2) requires, no later than one year after submitting the plan

required under section 501(a)(1), that VA submit to SVAC and HVAC a report on the number of

mental health providers hired within VA during the one-year period preceding the report submission.

Section 501(b) requires VA, no later than one year after enactment (i.e., October 17, 2021), to develop an occupational series for LPMHCs and MFTs working for VA.

Section 502: Establishment of Department of Veterans Affairs Readjustment

Counseling Service Scholarship Program

Background

To assist VHA with recruitment and retention of both clinical and nonclinical staff, Congress has authorized scholarships and student loan repayment programs under the umbrella of the Health

Professional Educational Assistance Program (HPEAP).155 These include, among others, the

Health Professional Scholarship Program (HPSP),156 the Department of Veterans Affairs

Employee Incentive Scholarship Program (EISP),157 and the Visual Impairment Education

Assistance Program (VIOMPSP).158 However, no specific scholarship program was authorized to

recruit and retain Readjustment Counselors serving at Vet Centers in the Readjustment Counseling Service (RCS).

Provision

Section 502(a) amends current law and adds a new subchapter IX, Readjustment Counseling

Service Scholarship Program. In the following paragraphs, “this section” refers to this new subchapter IX of chapter 76 of Title 38, and its subdivisions.

Requirement for program

This section requires the Secretary to implement a new Department of Veterans Affairs Readjustment Counseling Service Scholarship Program under the HPEAP.

Eligibility

This section stipulates that, to be eligible for the scholarship program, an individual must be accepted for enrollment or enrolled in a course of education leading to a terminal degree in

psychology, social work, marriage and family therapy, or mental health counseling, at an

accredited educational institution or training program that is approved by the Secretary. An

155 38 U.S.C. §§7601 et seq.

156 38 U.S.C. §§ 7611 et seq.

157 38 U.S.C. §§7671 et seq. 158 38 U.S.C. §§7501 et seq.



individual would need to meet VHA qualification standards for employment, and would need to agree to the requirements stipulated under the scholarship program.

Priority in Selecting Individuals

This section requires the Secretary to prioritize individuals who are veterans, or who agree to be

employed by a Vet Center located in a medically underserved area, as designated by the Public

Health Service Act, and in a state with a per capita population of veterans of more than 5%, as defined by the National Center for Veterans Analysis and Statistics and the Census Bureau.

Agreement

This section stipulates that a participant in the scholarship program must agree to enter into an

agreement with the Secretary. The agreement would describe the number of school years during

which the scholarship funds would be provided to the participant, and would require the participant to commit to a six-year period of obligated service at a Vet Center following the completion studies.

Obligated service

This section requires that each participant in the scholarship program provide service as a full-

time employee at a Vet Center for a period of six years following the completion studies. The Secretary is required to provide 60 days advance notice regarding the service commencement date.

Breach of agreement

This section stipulates that a participant in the scholarship program who has entered into an

agreement with the Secretary, and who does not accept scholarship payments, will have to pay

$1,500 in damages. This penalty is in addition to any liabilities related to the obligated period of service. In addition, this section stipulates that the participant will be liable if the participant fails

to complete course of study or does not obtain a required degree certificate. Penalties pertaining

to the obligated period of service do not apply in a situation where VA is required to use

Reduction in Force (RIF) procedures. Penalties are required to be paid within one year following the breach of the agreement.

Effective Date

Section 502(c) requires the Secretary to begin awarding Readjustment Counseling Service

Scholarships no later than one year after the date of the enactment of this act (i.e., October 17, 2021).

Section 503: Comptroller General Report on Readjustment Counseling Service

of Department of Veterans Affairs

Background

VA provides readjustment counseling services to veterans, servicemembers, and their families in

community settings through Vet Centers.159 Services provided at Vet Centers address bereavement, PTSD, military sexual trauma, and substance use assessment and referral, among

other topics. Individuals do not have be enrolled in VA health care to qualify for readjustment

counseling at Vet Centers. To qualify for readjustment services, a veteran or servicemember must

have either (1) served on active duty in a combat theater of operations, (2) provided direct

159 38 U.S.C. §1712A.



emergency medical or mental health care or mortuary services to the causalities of combat

operations or hostilities, or (3) engaged in combat in a theater of combat operations by remotely

controlling an unmanned aerial vehicle.160 Certain family members are also eligible for

readjustment counseling services if they live with an eligible veteran or servicemember. This

differs from qualification for enrollment in VA health care, which requires a veteran to meet specific criteria (e.g., means tests or disability status) to qualify for enrollment.161

Provision

Section 503 requires GAO to submit a report, no later than one year after enactment (i.e., October

17, 2021), to SVAC and HVAC on readjustment counseling services provided through VA. The

report must include an assessment of (1) the adequacy of Vet Center treatment, counseling, and

other services; (2) the efficacy of outreach efforts; (3) barriers to care; (4) the efficacy and frequency of the use of telehealth by the RCS to provide mental health services; (5) the feasibility

and advisability of expanding eligibility for services; (6) the use of Vet Centers by members of

the reserve components of the Armed Forces who were never activated; (7) the use of Vet Centers

by eligible family members of former members of the Armed Forces; (8) the efficacy of group

therapy and the level of training of providers; (9) the efficiency and effectiveness of the task organization structure of Vet Centers; and (10) the use of Vet Centers by Native American

veterans.162 This section requires GAO to make recommendations for most of the required assessments.

Section 504: Expansion of Reporting Requirements on Readjustment

Counseling Services of Department of Veterans Affairs

Background

The National Defense Authorization Act for Fiscal Year 2013 (P.L. 112-239) established the

organizational structure, authority, and funding source of Readjustment Counseling Services

within VA.163 This act included an annual reporting requirement on the activities of the Readjustment Counseling Service during the preceding calendar year.

Provision

Section 504 amends reporting requirements for Readjustment Counseling Services. First, this

section requires that the annual report identify resources required to meet demand for unmet

needs such as additional staff, locations, infrastructure, infrastructure improvements, and additional mobile Vet Centers. Second, this section adds additional requirements for reports

submitted in even-numbered years. Such reports must additionally include a prediction of (1)

trends in demand for care, (2) long-term investments required with respect to the provision of

care, (3) requirements relating to maintenance of infrastructure, and (4) other capital investment requirements.

160 Department of Veterans Affairs, Veterans Health Administration, “Readjustment Counseling Se rvices,” VHA

Directive 1500, January 26, 2021, pp. 2-3. Veterans who accessed readjustment services prior to January 2, 2013, are

eligible regardless of combat experience.

161 For more information on enrollment and eligibility for VA health care, see CRS Report R42747, Health Care for

Veterans: Answers to Frequently Asked Questions.

162 As defined in 38 U.S.C. §3765. 163 38 U.S.C. §7309.



Section 505: Briefing on Alternative Work Schedules for Employees of

Veterans Health Administration

Background

This section was derived from the VA ECHO Act (H.R. 8212), introduced by Representatives Joe

Cunningham and Jim Banks in the 116th Congress. Current VHA policy requires that VAMCs and CBOCs treating 10,000 or more unique primary care veteran patients in a fiscal year must provide

individuals with access to appointments for a minimum of four extended hours per week in both a

primary care clinic and a mental health clinic, and a minimum of one extended hour per month in a women veteran’s clinic.164

Provision

Section 505 codifies existing policy of providing extended hours and requires the Secretary to

conduct, no later than 180 days from enactment of this act (i.e., April 15, 2021), a survey of

veterans on their attitudes toward offering appointments outside usual operating hours. In

addition, this section requires that the Secretary brief SVAC and HVAC no later than 270 days

from enactment (i.e., July 14, 2021) on the (1) feasibility and advisability of offering appointments outside of normal operating hours and (2) the effectiveness of offering these

appointments. The briefing is required to include, among other things, the findings of the survey and feedback from specified employees.

Section 506: Suicide Prevention Coordinators

Background

Suicide prevention coordinators (SPCs) are VHA employees tasked with coordinating care for

veterans at high risk for suicide who are receiving care within VHA. As part of this care coordination, SPCs can be assigned referrals from the VCL to ensure continuity of care with a

veteran’s local VHA provider. Among other responsibilities, SPCs also conduct outreach and

disseminate best practices related to suicide prevention. As of April 2019, VA had employed

approximately 444 SPCs—with at least one SPC at each VAMC and very large CBOC165—

responsible for managing care for nearly 30,000 high-risk veterans, equating to the care coordination of nearly 90 veterans per SPC.166 According to an internal 2018 analysis, VHA determined a need for 246 additional SPCs to meet demand.167

In response to concerns that SPCs were being overworked and were understaffed, Congress enacted legislation in the 116th Congress requiring GAO to look further into the issue.168 Among

164 Department of Veterans Affairs, Veterans Health Administration, “ Outpatient Clinic Practice Management,” VHA

Directive 1231(1) October 18, 2019, amended March 10, 2020. p.3.

165 Department of Veterans Affairs, Veterans Health Administration, “Uniform Mental Health Services in VA Medical

Centers and Clinics,” VHA Handbook 1160.01, amended November 16, 2015. Very large CBOC are those that serve

more than 10,000 unique veterans each year. 166 H.Rept. 116-70.

167 U.S. Congress, House Committee on Veterans’ Affairs, Testimony before the House Committee on Veteran’s

Affairs, Tragic Trends: Suicide Prevention Among Veterans, prepared by Keita Franklin, Ph.D. on behalf of Dr.

Richard Stone, Veterans Health Administrat ion, 116th Cong., 1st sess., April 29, 2019.

168 P.L. 116-96.



other things, GAO was required to examine the responsibilities and workload, training, and

vacancy rates of SPCs, and the extent to which the Secretary provides oversight of SPCs. In its

April 2021 report, GAO noted that SPCs are vulnerable to burnout and turnover, given the

increasing number of suicide initiatives offered by VHA and the resulting increasing volume of

veterans identified at high risk for suicide. Further, GAO found that VHA had not evaluated

staffing needs considering effects of program growth on workload, leaving facilities susceptible to understaffing.169

Provision

Section 506(a) requires the Secretary, no later than one year after enactment (i.e., October 17,

2021), to ensure that each VAMC has at least one SPC. Section 506(b) requires the Secretary, in

consultation with OMHSP, to conduct a study, no later than one year after enactment (i.e., October 17, 2021), on the feasibility of creating a SPC program office. Among other things, this

feasibility assessment would examine whether the Director of the Suicide Prevention program

could have ultimate supervision over the SPC program office. Section 506(c) requires the

Secretary, no later than 90 days after completion of the study under subsection (b), to submit a

report to SVAC and HVAC. This report shall include (1) an assessment of the feasibility and advisability of the SPC program office; (2) a review of current staffing ratios for SPCs and

suicide prevention case managers in comparison to current staffing ratios for mental health

providers within each VAMC; and (3) a description of the duties of SPCs to better define, delineate, and standardize specified qualifications and performance objectives.

Section 507: Report on Efforts by Department of Veterans Affairs to Implement

Safety Planning in Emergency Departments

Background

In 2010, VA implemented a clinical demonstration project at five sites known as the Suicide

Assessment and Follow-up Engagement: Veteran Emergency Treatment (SAFE VET) program. The program was designed to help suicidal veterans seen at VA emergency departments or mental

health urgent care settings through administration of a veteran-focused, clinical safety plan

intervention, including an outreach protocol following discharge.170 The program was associated

with positive outcomes, and based on those findings, VA launched a second, larger program in

September 2018, the Safety Planning in Emergency Departments program of the Department of

Veterans Affairs (SPED). SPED is a program for veterans presenting to emergency departments who are determined to be at risk for suicide and are safe to be discharged home. The program

combines safety planning interventions with follow-up phone calls after discharge from

emergency departments or urgent care centers to transition veterans to outpatient mental health

care. SPED primary coordinators are the point of contact responsible for administering the

program at a VAMC. As of FY2020, VA had implemented safety plans in over 60% of emergency departments, with a goal of 90% by FY2021.171

169 U.S. Government Accountability Office, VA Health Care: Efforts Needed to Ensure Effective Use and Appropriate

Staffing of Suicide Prevention Teams, GAO-21-326, April 2021, https://www.gao.gov/assets/gao-21-326.pdf.

170 Kerry L. Knox, Barbara Stanley, Glenn W. Currier, et al., “An Emergency Department -Based Brief Intervention for

Veterans at Risk for Suicide (SAFE VET),” American Journal of Public Health , vol. 102, no. suppl. 1 (2012), pp. S33-

S37. 171 Department of Veterans Affairs, Agency Priority Goal Action Plan, Suicide Prevention, FY 2020 Q4 Update ,



Provision

Section 507 requires the Secretary to submit a report to HVAC and SVAC no later than 180 days

from enactment (i.e., April 15, 2021) on the efforts to implement the SPED program for veterans

presenting to a VHA emergency department or urgent care center who are assessed to be at risk

for suicide but are safe to be discharged home. The report is required to include, among other things (1) an assessment of implementation of policies and procedures of the SPED program at

each VA medical center; (2) a description of how SPED primary coordinators are deployed; (3) an

assessment of the feasibility and advisability of expanding SPED coordinator deployment; (4) an

assessment of the feasibility and advisability of providing services under the SPED program via

telehealth; (5) a description of the status of current capabilities and use of tracking mechanisms to

monitor compliance, quality, and patient outcomes; and (6) recommendations regarding how VA can better implement the SPED program.

Title VI: Improvement of Care and Services for Women Veterans

Women veterans are one of the fastest-growing veteran demographics, and the number of women

using VHA care approximately tripled from 2000 to 2019.172 However, women veterans can

experience certain gender-specific barriers to accessing and receiving VHA care.173 The Veterans

Health Care Act of 1992 (P.L. 102-285) first authorized VA to provide gender-specific services.

Subsequent legislation has expanded services available to women veterans.174 This title includes two provisions that would (1) expand the capabilities of the Women Veterans Call Center (a

hotline for women veterans) and (2) require VHA to publicly post relevant information for women veterans.

Section 601: Expansion of Capabilities of Women Veterans Call Center to

Include Text Messaging

Background

VA administers a hotline for women veterans, the Women Veterans Call Center (WVCC). In

addition to responding to incoming calls, the WVCC conducts outreach to women veterans

through outgoing calls. The WVCC provides women veterans with information about available benefits, eligibility for VHA services, and resources. As of August 31, 2019, the WVCC had

received 79,692 calls and made 1,213,639 calls, with 632,000 of those calls resulting in speaking with a veteran or leaving a voicemail.175

January 2021, p. 8, https://trumpadministration.archives.performance.gov/veterans_affairs/

FY2021_january_Suicide_Prevention.pdf.

172 Department of Veterans Affairs, “New text feature available through VA’s Women Veterans Call Center,” blog

post, April 23, 2019, https://www.blogs.va.gov/VAntage/59278/new-text-feature-available-vas-women-veterans-call-

center/. 173 Department of Veterans Affairs, Study of Barriers for Women Veterans to VA Health Care, April 2015,

https://www.womenshealth.va.gov/docs/

Womens%20Health%20Services_Barriers%20to%20Care%20Final%20Report_April2015.pdf .

174 P.L. 103-452 provided authority for counseling and treatment for military sexual trauma. Since 2017, appropriations

acts have authorized the use of assisted reproductive technology, such as in -vitro fertilization for certain veterans. For

more information on gender-specific services for veterans, see CRS In Focus IF11082, Veterans Health

Administration: Gender-Specific Health Care Services for Women Veterans. 175 Department of Veterans Affairs, FY2021 Congressional Budget Submission, Volume II: Medical Programs and



The WVCC connects with women veterans though a call, text message, or online chat.176 The

WVCC added the online chat feature in May 2016 and added text messaging capabilities in April 2019.177

Provision

Section 601 codifies existing practice by requiring the Secretary to expand the capabilities of the WVCC to include text messaging.

Section 602: Requirement for Department of Veterans Affairs Internet Website

to Provide Information on Services Available to Women Veterans

Background

VHA administers a program for women veterans that includes preventive care, acute care, and reproductive health services.178 VHA operates a website that directs women veterans to available services, provides outreach materials, and relevant news, among other things.179

Provision

Section 602(a) requires the Secretary to survey VA websites and information resources in effect on the date before enactment of this act (i.e., October 16, 2020) and to publish a website that

serves as a centralized source of information about benefits and services available to veterans.

Section 602(b) requires, among other things, that the website provide women veterans with

information regarding services available in their district and a list of appropriate staff for benefits

available through the Veterans Benefits Administration (VBA), the National Cemetery

Administration (NCA), and other entities. The Secretary is also required to ensure that the information is updated at least once every 90 days. In addition, the Secretary must ensure that

outreach conducted under the comprehensive program for suicide prevention among veterans180

includes information regarding the website. Section 602(e) specifies that funds needed to carry out this section shall be derived from available funds used to publish VA websites.


fy2021VAbudgetVolumeIImedicalProgramsAndInformationTechnology.pdf . 176 The call center is available Monday through Friday 8:00 a.m. to 10:00 p.m. ET, and Saturday from 8:00 a.m. to

6:30 p.m. ET . For more information, see https://www.womenshealth.va.gov/WOMENSHEALTH/ProgramOverview/

wvcc.asp.

177 Department of Veterans Affairs, “New text feature available through VA’s Women Veterans Call Center,” blog

post, April 23, 2019, https://www.blogs.va.gov/VAntage/59278/new-text-feature-available-vas-women-veterans-call-

center/. 178 Department of Veterans Affairs, Veterans Health Administration, “Healthcare Services for Women Veterans,” VHA

Directive 1330.01(3), June 19, 2020.

179 The website is available at https://www.womenshealth.va.gov/WOMENSHEALTH/index.asp.

180 38 U.S.C. §1720F(i).



Title VII: Other Matters

Section 701: Expanded Telehealth from Department of Veterans Affairs

Background

On July 12, 2016, VA established the Office of Connected Care (OCC) within VHA. The goal of

OCC is to “deliver [information technology (IT)] health solutions that increase a [v]eteran’s

access to care and supports a [v]eteran’s participation in their health care.”181 OCC administers the following four VA telehealth programs:182

VA Telehealth Services, according to VA, “[improve] convenience to [v]eterans

by providing access to care from their homes or local communities when they

need it”;

My HealtheVet is the web-based electronic health record (EHR) for veteran

patients through which veterans can view and download electronic protected

health information (ePHI);

VHA Innovation Program is an annual competitive program that allows VA

staff and key stakeholders in the private sector to submit innovative ideas on

enhancing VA care; and

VA Mobile Health (VA Mobile) develops mobile apps.183

Provision

Section 701 requires the Secretary to establish a new grant program for the expansion of

telehealth capabilities and the provision of telehealth services. The Secretary is required to ensure, to the extent practicable, that the grant program gives preference to entities in rural areas. Grants

may be awarded for a large variety of specified purposes. In addition, the section authorizes the

Secretary to enter into agreements with entities that seek to establish telehealth access points but

do not require grant funding. The Secretary is required to complete an assessment of barriers to

accessing telehealth services no later than 18 months from enactment (i.e., April 17, 2022). No

later than 120 days after completion of the assessment, the Secretary is required to submit a report to SVAC and HVAC on the assessment, including any recommendations for legislative or administrative action.

181 Department of Veterans Affairs, “Telehealth Services and Connected Care,” VHA Telehealth Quarterly, January

2016, p. 2, winter edition.

182 This list was adapted from VA, Connected Care, https://connectedcare.va.gov/terms/connected-health/single/About.

183 For more information on VA telehealth services, see CRS Report R45834, Department of Veterans Affairs (VA): A

Primer on Telehealth.



Section 702: Partnerships with Non-Federal Government Entitles to Provide

Hyperbaric Oxygen Therapy to Veterans and Studies on the Use of Such

Therapy for Treatment of Posttraumatic Stress Disorder and Traumatic Brain

Injury

Background

Hyperbaric oxygen therapy (HBOT) is intended to increase the supply of oxygen to the blood for

certain types of injuries that can cause a deficiency in the amount of oxygen reaching the tissues

(i.e., hypoxia). HBOT works by having an individual intermittently breathe near 100% oxygen in

a hyperbaric chamber where the air pressure is at least 1.4 times greater than normal.184 This enhanced oxygen availability has been associated with healing processes that require large

amounts of oxygen (e.g., reducing swelling).185 Hyperbaric chambers are considered medical

devices and require clearance from the Food and Drug Administration (FDA) to be marketed.

FDA has cleared HBOT for specific uses, including burns, necrotizing infections, and carbon

monoxide poisoning, among others. FDA has not yet cleared HBOT to treat traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), which are considered signature wounds experienced by servicemembers and veterans of the conflicts in Iraq and Afghanistan.

There has been interest in the use of HBOT to treat these often co-occurring conditions, given the potential effects of these conditions on the white matter of the brain. However, separate reviews

conducted by GAO in 2015186 and VA in 2018 suggest that the evidence regarding the

effectiveness of these treatments for both TBI and PTSD is mixed. This led VA to conclude, “In

summary, the large treatment benefits demonstrated for HBOT in uncontrolled case series have

not been easily replicated in well-controlled [randomized controlled trials] RCTs. Potential explanations for this include that the potential benefits are subtle and demonstration requires

larger RCTs, HBOT is in fact ineffective, and/or the sham [control group] design has indeed been

problematic. We are unconvinced that the current evidence clearly points to one explanation over another. We simply still don’t know.”187

In 2017, VA, through its Center of Compassionate Innovation (CCI) within the Office of

Community Engagement, started a pilot program that offers HBOT as a treatment option for

certain veterans. Specifically, these veterans have persistent PTSD and tried two evidence-based

treatments that provided no decrease in symptoms.188 In a recent press release, the Eastern Oklahoma VA Health Care System and the VA Northern California Health Care System were

mentioned as VAMCs that would initially provide this care. Since that time, other VAMCs have

been added to the pilot program. In a 2019 update on its website, VA noted that four VAMCs were

184 Richard E. Moon et al., Hyperbaric Oxygen Therapy Indications, Undersea and Hyperbaric Medical Society, 14 th

Edition, North Palm Beach, FL, 2019, https://www.uhms.org/images/UHMS-Reference-Material.pdf.

185 Kim Peterson, Donald Bourne, Johanna Anderson, et al., Evidence Brief: Hyperbaric Oxygen Therapy (HBOT) for

Traumatic Brain Injury and/or Post-traumatic Stress Disorder, Department of Veterans Affairs, Portland, OR,

February 2018, https://www.ncbi.nlm.nih.gov/books/NBK499535/pdf/Bookshelf_NBK499535.pdf. 186 U.S. Government Accountability Office, Research on Hyperbaric Oxygen Therapy to Treat Traumatic Brain Injury

and Post-Traumatic Stress Disorder, GAO-16-154, December 2015, https://www.gao.gov/assets/680/674334.pdf.

187 Kim Peterson, Donald Bourne, Johanna Anderson, et al., Evidence Brief: Hyperbaric Oxygen Therapy (HBOT) for

Traumatic Brain Injury and/or Post-traumatic Stress Disorder, 2018, p. 19.

188 Department of Veterans Affairs, “ VA to Provide Hyperbaric Oxygen Therapy to Some Veterans with Chronic

PTSD,” November 2017, https://www.va.gov/opa/pressrel/pressrelease.cfm?id=3978.



currently participating in the pilot program (although did not specify which sites). 189 According to

the North Dakota Department of Veterans Affairs, the Fargo VAMC was the fifth site added to the pilot program.190 Each of these VAMCs partners with local providers to provide HBOT.

Provision

Section 702(a) allows the Secretary, in consultation with CCI, to enter into partnerships with nonfederal government entities to provide HBOT to veterans as part of research into the

effectiveness of this therapy. Such partnerships may include those that focus on conducting

research, reviewing research, creating industry working groups to determine standards for

research, or providing HBOT to veterans for the purpose of conducting research on the

effectiveness of the therapy. Federal funds may be used only to coordinate and administer partnerships under subsection (a).

Section 702(b) requires the Secretary, no later than 90 days after enactment (i.e., January 15,

2021) and in consultation with CCI, to review the effectiveness of HBOT using an objective and quantifiable method (e.g., an FDA-approved or cleared device that assesses traumatic brain injury

(TBI) by tracking eye movement). Section 702(c) requires the Secretary, no later than 90 days

after enactment (i.e., January 15, 2021) and in consultation with CCI, to conduct a systematic

review of literature on the off-label use of HBOT to treat PTSD and TBI among veteran and

nonveteran populations. The review is required to include, among other things, an assessment of

current parameters for research on VA use of HBOT and a comparative analysis of tests and questionnaires used to study PTSD and TBI in research conducted by VA, as well as other federal

and nonfederal organizations. It is required to be completed no later than 180 days after it is

started, and the Secretary is required to submit a report on the results of the review to SVAC and HVAC no later than 90 days after completion of the review.

Section 702(d) requires the Secretary, no later than 120 days after completion of the review

conducted under subsection (c) and in consultation with CCI, to conduct a study on the efficacy

and effectiveness of HBOT for PTSD and TBI, as is currently being offered through VA’s pilot

program. This study is required to be completed no later than three years after commencement. No later than 90 days after the study is completed, the Secretary is require to submit to SVAC and

HVAC a report on the results of the study. The report shall include the Secretary’s

recommendation as to whether HBOT should be made available to all veterans with PTSD and TBI.

Section 703: Prescription of Technical Qualifications for Licensed Hearing Aid

Specialists and Requirement for Appointment of Such Specialists

Background

The Veterans Mobility Safety Act of 2016 (P.L. 114-256) amended VHA’s appointment authority

to include licensed hearing aid specialists and those whose qualifications can be prescribed by the Secretary. This provision was derived from the Veterans Hearing Aid Access and Assistance Act

189 Department of Veterans Affairs, “ The Center for Compassionate Care Innovation supports treatments that may help

Veterans with PTSD: Hyperbaric Oxygen Therapy (HBOT),” August 9, 2019, https://www.va.gov/healthpartnerships/

updates/cci/08092019.asp. 190 North Dakota Department of Veterans Affairs, “Hoeven, Cramer, Armstrong: VA Extends Fargo VA HBOT

Demonstration Program, Expands Program to Include Jamestown Regional Medical Center and Increases Treatment

Referrals for Veterans,” October 15, 2020, https://www.nd.gov/veterans/news/va-extends-fargo-va-hbot-

demonstration-program.



(S. 564; 114th Congress). However, VHA did not develop basic qualification standards and work

assignments for this occupation and did not exercise this discretionary authority provided in the act to hire hearing aid specialists. In reports to Congress, VHA stated that

there are technical barriers to establishing qualification standards for hearing aid specialists.... To be eligible for appointment to the title 38 positions in VA, a profession must have established qualifications that include standards for education and professional

training that are applicable for all states. Presently, the hearing aid specialist occupation has no consistent national education requirements and no standardized professional training, resulting in highly variable skill sets from state to state. Most states (33) require

only a high school education for hearing aid specialists to receive a license. Nine states have no educational requirement and eight states require an associate degree for state

licensure…. When this profession establishes a functional national standard for hearing aid specialists that addresses the necessary education, training and licensure requirements, VA will use the authority to revise the standards when national standards are in place.191

Provision

Section 703 requires the Secretary to prescribe technical qualifications and appointment requirements for licensed hearing aid specialists.

Technical Qualifications

Section 703(a)(1) requires the Secretary to prescribe the technical qualifications that are required

for appointment as licensed hearing aid specialists in VHA. These qualification standards are to be prescribed no later than 180 days after the date of the enactment of this act (i.e., April 15, 2021).

Elements for Qualifications

Section 703(a)(2) stipulates that when prescribing qualifications, the Secretary must ensure that

the qualifications for hearing aid specialists are in keeping with licensure standards of a majority of states, have the competencies needed as hearing aid specialists, and include any other competencies required by the Secretary to provide care.

Authority to Set and Maintain Duties

Section 703(b) requires the Secretary to retain the authority to set and maintain the duties for licensed hearing aid specialists.

Appointment

Section 703(c) requires the Secretary to appoint at least one licensed hearing aid specialist at each VAMC no later than September 30, 2022.

Reporting Requirements

Section 703(d) requires the Secretary to submit an annual report to SVAC and HVAC on the

appointment of licensed hearing aid specialists. The first such report must be submitted no later than September 30, 2022. The annual report must include, among other things, the following

elements: assessing the progress of appointments of licensed hearing aid specialists in VAMCs,

potential challenges facing appointments, and assessing access of patients to comprehensive VA hearing health services.

191 Department of Veterans Affairs, Report on Timely Access of Veterans to Hearing Health Services Through the

Department of Veterans Affairs, Report to Congress, December 2020, p. 2.



Section 704: Use by Department of Veterans Affairs of Commercial

Institutional Review Boards in Sponsored Research Trials

Background

The HHS Human Subject Regulations are a core set of federal standards for protecting human

subjects in HHS-sponsored research.192 These regulations are commonly referred to as the “Common Rule” because the same requirements have been adopted by many non-HHS federal

departments and agencies, including VA, which apply the regulations to the research they fund.

Under the Common Rule, research protocols must be approved by an Institutional Review Board

(IRB) to ensure that the rights and welfare of research subjects are protected.193 The rule lists

several criteria for IRB approval, including the requirement that researchers obtain the informed consent of their research subjects.194 HHS has promulgated additional protections for certain

vulnerable populations involved in research. Those groups include pregnant women, human fetuses, and neonates; prisoners; and children.195

VHA Directive 1200.05 (“Requirements for the Protection of Human Subjects in Research”)

“defines the procedures for implementing the Federal Policy for the Protection of Human

Subjects, known as the Common Rule, and other applicable Federal requirements for the protection of human subjects in research.”196

Provision

Section 704 requires the Secretary, no later than 90 days after enactment (i.e., January 15, 2021),

to allow sponsored clinical research of VA to use accredited commercial IRBs to review research

proposal protocols. This must be carried out through revision of VHA Directive 1200.05, titled

‘‘Requirements for the Protection of Human Subjects in Research.” Further, the Secretary is

required to identify accredited commercial IRBs and to establish a process to modify existing approvals in the case that a commercial IRB loses its accreditation. Finally, the Secretary is

required, no later than 90 days after the revisions of Directive 1200.05 are complete and annually

thereafter, to submit to SVAC and HVAC a report on all IRB approvals used by VA, including central IRBs and commercial IRBs, as specified.

Section 705: Creation of Office of Research Reviews Within the Office of

Information and Technology of the Department of Veterans Affairs

Background

Conducting medical research is one of VA’s statutory missions.197 As required by law, the medical

and prosthetic research program (medical research) focuses on research into the special health

192 45 C.F.R. Part 46, Subpart A.

193 45 C.F.R. §46.109.

194 45 C.F.R. §46.111. 195 45 C.F.R. Part 46, Subparts B (pregnant women, fetuses, neonates), C (prisoners), and D (children).

196 Department of Veterans Affairs, VHA Directive 1200.05 “Requirements for the Protection of Human Subjects in

Research,” amended March 3, 2020, p. 1.

197 38 U.S.C. §7303.



care needs of veterans.198 Although VHA’s medical research program is an intramural program,

industry-funded research studies, as well as collaborative research studies with private and/or

nonprofit entities, could be performed at VAMCs. VHA has a long history of nongovernmental-financed studies and private sector collaboration in its medical research program.199

Provision

Section 705 requires the Secretary to establish a new Office of Research Reviews within the

Office of Information and Technology within one year of enactment of this act (i.e. , October 17,

2021). The Office of Research Reviews will be responsible for conducting centralized security

reviews and completing security processes for approved research projects, including multisite

clinical trials, funded by non-VA sources. In addition, the office is required to develop and

maintain a list of officially approved commercial software used in clinical trials, and to develop appropriate timelines for security reviews. One year after the establishment of the Office of

Research Reviews, the Secretary is required to submit a report to SVAC and HVAC on activities of the office.

Provisions in Veterans COMPACT Act of 2020

Title I: Improvement of Transition of Individuals to Services from


Transitioning from the military to civilian life can be a time of increased risk for suicide. One

research study found that this risk may be elevated for years after the transition.200 This title includes provisions that assist with this transition by (1) authorizing a pilot program that

designates relatives and friends to receive information about assistance and benefits available to

veterans, and (2) requires VA to report to specified committees of Congress on the status of Solid

Start, a transition assistance program that conducts outreach to veterans at certain points during the first year of separation from the military.

Section 101: Pilot Program on Information Sharing Between Department of

Veterans Affairs and Designated Relatives and Friends of Veterans Regarding

Assistance and Benefits Available to the Veterans

Background

As VA notes in its national strategy for preventing veteran suicide, “family members, friends, co-

workers, and others can play an important role in recognizing when a Veteran is in crisis and

198 38 U.S.C. §7303(a)(3).

199 Marguerite T . Hays, A Historical Look at the Department of Veterans Affairs Research and Development Program ,

Department of Veterans Affairs, p. 98, https://www.research.va.gov/pubs/ord-history.cfm.

200 Department of Veterans Affairs, “Help With Readjustment and Social Support Needed for Veterans Transitioning

From Military Service,” https://www.mentalhealth.va.gov/suicide_prevention/docs/

Literature_Review_Military_Separation_508_FINAL_05-24-2019.pdf.



connecting the Veteran with sources of help. However, many of these people may not know the warning signs of suicidal behavior or where a distressed person can go for help.”201

Senator Kyrsten Sinema introduced the Sergeant Daniel Somers Veterans Network of Support Act of 2019 in November 2019, which requires the Secretary to carry out a two-year pilot program on

information sharing between VA and designated persons regarding assistance and benefits

available to veterans.202 The act was subsequently passed in the Senate in June 2020 and was

included as Section 101 of the Veterans COMPACT Act. The bill was named after Sergeant

Daniel Somers, who was diagnosed with PTSD and traumatic brain injuries following his return home from two tours in Iraq, and who died by suicide in 2013.203

Provision

Section 101(a) requires the Secretary to start a pilot program, no later than one year after

enactment (i.e., December 5, 2021), for a duration of at least two years, that encourages Armed

Forces members, before transitioning to civilian life, to designate up to 10 people to whom VA may disseminate specified information regarding assistance and benefits available to veterans.

When making such a designation, the veteran is required to provide necessary contact information

for the designees, including an email address. The pilot program would also provide the

designees, within 30 days after being designated, the option to elect to receive information

regarding assistance and benefits, and such information would be distributed at least quarterly to

the designees. Among other things, the specified information would include VA services and benefits offered to veterans and their families, services available through community partner

organizations to support veterans and their families, and a toll-free telephone number through

which designees may request information. Disclosure of such information may not violate

privacy requirements of the Armed Forces specified in statute or regulation.204 Veterans may

participate in the pilot program only if they voluntarily elect to do so. Designees may participate only if they elect to receive the specified information, and they may opt out of the program upon request.

Section 101(b)(1) requires the Secretary, no later than one year after the start of the pilot program and annually thereafter, to administer a survey to designees in the pilot program regarding the

quality of information disseminated. Among other things, the survey would solicit feedback on

satisfaction with the pilot program, recommendations for improving the pilot program, and

reasons for opting in or out of the pilot program. Section 101(b)(2) requires the Secretary, no later

than three years after the start of the pilot program, to submit a final report on the program to the HVAC and SVAC. The report is required to include, among other things, the number of

participants enrolled in the pilot program who are veterans, the number of persons who opted in

or out of the pilot program, and identification of necessary legislative or administrative action if the pilot program is made permanent.

201 Office of Mental Health and Suicide Prevention, National Strategy for Preventing Veteran Suicide, 2018-2028, Department of Veterans Affairs, p. 17, https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-

Health-and-Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf.

202 S. 2864 (116th Congress).

203 U.S. Senator Krysten Sinema, “Breaking: Sinema’s Sgt. Daniel Somers Veterans Network of Support Act Signed

Into Law,” December 7, 2020, https://www.sinema.senate.gov/breaking-sinemas-sgt-daniel-somers-veterans-network-

support-act-signed-law. 204 As specified in Section 101(a)(5), such statutory requirements include 5 U.S.C. §552a (The Privacy Act of 1974)

and P.L. 104-191 (the Health Insurance Portability and Accountability Act of 1996, HIPAA).



Section 102: Annual Report on Solid Start Program of Department of

Veterans Affairs

Background

To address requirements associated with the January 2018 EO 13822 “Supporting our Veterans

During Their Transition from Uniformed Service to Civilian Life,” VA, in collaboration with DOD and DHS, launched Solid Start in December 2019. Solid Start is a transition assistance

program that conducts outreach to newly separated servicemembers, regardless of separation type

or characterization of service. Such outreach generally occurs at the 90-, 180-, and 365-day mark

during the first year after separation, and the calls provide new veterans education about and

assistance with accessing certain VA benefits. According to VA, VBA successfully connected with 70,000 newly separated servicemembers during the first year of the program (2020).205

Provision

Section 102 requires the Secretary to submit to SVAC and HVAC an annual report on VA’s Solid

Start program no later than 180 days after enactment (i.e., June 3, 2021) and every five years

thereafter. The report is required to include specified information with respect to each veteran called or emailed under the program, including the Armed Force in which the veteran served and

whether the call or email resulted in a call to the VCL, and any change to the Solid Start program

implemented since the date of the previous such report, among other things. The report may not contain any of the veteran’s personally identifiable information.

Title II: Suicide Prevention

As VHA continues to expand suicide prevention initiatives and create new programs, more

veterans at risk for suicide are able to be identified.206 However, as these veterans are identified, need for services also increases. Further, as suicide can arise from numerous factors, a

multifactorial approach is needed to reach as many at-risk veterans as possible. This title includes

provisions that address suicide prevention by (1) requiring the Secretary to provide acute crisis

care for emergent suicide symptoms; (2) requiring the Secretary to create an education pilot

program for family members and caregivers on matters related to coping with mental health disorders in veterans; (3) requiring the Secretary to establish a task force on outdoor recreation;

(4) requiring VHA to contact all enrolled veterans who have not received care in the past two

years to encourage them to receive a comprehensive medical examination, including a mental health evaluation; and (5) requiring annual VA police crisis intervention training.

Section 201: Department of Veteran Affairs Provision of Emergent

Suicide Care

Background

The Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (P.L. 107-

135) provided the Secretary broad authority to furnish hospital care or medical services in

205 Department of Veterans Affairs, “ VA Solid Start program makes strides in first year,” December 2, 2020,

https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5577. 206 U.S. Government Accountability Office, Efforts Needed to Ensure Effective Use and Appropriate Staffing of Suicide

Prevention Teams, GAO-21-326, April 2021, https://www.gao.gov/assets/gao-21-326.pdf.



emergency situations to any individual regardless of veteran status. This authority is generally

referred to as the humanitarian care authority. Furthermore, the Jeff Miller and Richard

Blumenthal Veterans Health Care and Benefits Improvement Act of 2016 (P.L. 114-315) requires

VA emergency departments to, at a minimum, screen an individual for a medical emergency. If

the facility determines that a medical emergency exists, the facility will provide care to stabilize

the individual’s emergency condition.207 The individual is generally billed for any emergency services provided.208

A former servicemember with a bad conduct or dishonorable discharge who is in distress and in need of emergency mental health services may be provided services under humanitarian care

provisions.209 Former servicemembers can access the VA system by calling the VCL or by visiting a VA emergency room, urgent care center, or VAMC.

Descriptions of Military Character of Discharge Honorable discharge applies when the quality of a servicemember’s service generally has met the

standards of acceptable conduct and performance of duty for military personnel, or is otherwise so

meritorious that any other characterization would be clearly inappropriate.

General (under honorable) discharge applies when a servicemember’s service has been honest and

faithful. Characterization of service as general (under honorable conditions) is warranted when the positive

aspects of a servicemember’s conduct or performance of duty outweigh negative aspects of the

servicemember’s conduct or performance of duty as documented in their service record.

Other-than-honorable discharge applies when separation is based on a pattern of behavior that

constitutes a significant departure from the conduct expected of servicemembers, or when separation is

based on one or more acts or omissions that constitute a significant departure from the conduct expected of

servicemembers. Factors that may lead to such a discharge include the use of force or violence to produce

serious bodily injury or death; abuse of a special position of trust; disregard by a superior of customary

superior-subordinate relationships; acts or omissions that endanger the security of the United States or the

health and welfare of other servicemembers; and deliberate acts or omissions that seriously endanger the

health and safety of other persons.

Bad-conduct discharge applies only to enlisted persons and may be adjudged by a general court-martial

and by a special court-martial. A bad-conduct discharge is less severe than a dishonorable discharge and is

designed as a punishment for bad conduct rather than as a punishment for serious offenses of either a civilian

or military nature. It is also appropriate for an accused servicemember who has been repeatedly convicted of

minor offenses and whose punitive separation appears to be necessary.

Dishonorable discharge applies only to enlisted persons and warrant officers who are not commissioned

and may be adjudged only by a general court-martial. A dishonorable discharge may be adjudged for any

offense in which a warrant officer who is not commissioned has been found guilty. It is reserved for those

who should be separated under conditions of dishonor, after having been convicted of offenses typically

recognized in civil jurisdictions as felonies, or of offenses of a military nature requiring severe punishment.

Source: CRS, adapted from the Department of Defense, Enlisted Administrative Separations, DOD Instruction

1332.14, effective April 12, 2019, and the Manual for Courts-Martial United States (2019 edition).

In FY2017, VHA started providing emergent mental health services to former servicemembers

with OTH administrative discharges. Eligible servicemembers were provided emergency

stabilization if they presented at a VAMC with an emergent mental health need. Those with an

OTH administrative discharge were able to receive care for their mental health emergency for an

207 Department of Veterans Affairs, Veterans Health Administration, Eligibility Determination, VHA Directive

1601A.02, amended October 15, 2020, and 38 U.S.C. §1784A.

208 38 U.S.C. §1784.

209 Department of Veterans Affairs, Veterans Health Administration, “Eligibility Determination,” VHA Directive

1601A.02, amended October 15, 2020.



initial period of up to 90 days, which included inpatient, residential, or outpatient care.210 These services are not provided to former servicemembers with bad-conduct or dishonorable discharges.

Provision

Section 201(a) amends current law and adds a new Section 1720J to title 38 of the U.S. Code. In

the following paragraphs, “this section” refers to the newly added Section 1720J and its subdivisions.

Emergent Suicide Care

This section would require the Secretary to provide emergent suicide care to those with an acute

suicidal crisis, in a VA facility, or to pay for care in a non-VA facility, or to reimburse for such care.

Eligibility

This section stipulates that individuals are eligible for emergent suicide care if they meet the

statutory definition of a “veteran,” meaning an “individual who served in the active military,

naval, or air service and who was discharged or released under conditions other than

dishonorable”;211 or a former servicemember, including those who served in the Reserve components and who meet each of the following criteria:212

Conditions of discharge: the veteran served on active duty and was discharged or

released under a condition that is not honorable (but not a dishonorable

discharge), or was discharged by court-martial (i.e., those with a dishonorable discharge or a discharge by court-martial would not be eligible for mental health


Duration of service: the veteran served for a period of more than 100 cumulative

days.

Conditions of service: the veteran (1) was deployed in a theater of combat

operations, in support of a contingency operation, or in an area at a time during

which hostilities occurred, including by controlling an unmanned aerial vehicle (UAV) from a location other than such theater or area; or (2) was the victim of a


harassment.

Not currently enrolled in VA’s health care system.

Period of Care

This section requires that care be provided for a period not to exceed 30 days as an inpatient or in

a crisis residential care facility; if such care is unavailable or not clinically appropriate, then care

must be provided on an outpatient basis for a period of no more than 90 days. After such time, if

210 Department of Veterans Affairs, “VA Secretary Formalizes Expansion of Emergency Mental Health Care to Former

Service Members With Other-Than-Honorable Discharges,” press release, June 27, 2017. Also see Memorandum from

Deputy Under Secretary for Health for Operations and Management (1ON) to Network Directors (10N1-23) and

Network Mental Health Leads (10N1-23), Eliminating Veteran Suicide: Emergency Services for Other Than

Honorable, June 26, 2017.


Year 2021 (P.L. 116-283) amended the term “veteran” to include “ space service.’’ The Office of the Law Revision

Counsel of the U.S. House of Representatives has not codified this change as of the date of this report. 212 38 U.S.C. §1720I(b).



the Secretary determines that such individual remains in an acute suicidal crisis, the Secretary could extend the period of care as appropriate.

Outreach and Notification Requirements

This section stipulates that an eligible individual, or someone else on behalf of the individual,

must notify the Secretary within seven days if such an individual receives emergent suicide care

at a non-VA facility. It also requires the following during the period when an eligible individual is receiving emergent suicide care:

If emergent suicide care is recommended by the VCL at a VAMC, then the VCL

must notify the SPC at the VAMC.

If the eligible individual receives emergent suicide care at a VAMC without the

VCL recommendation, then the SPC at the VAMC must be notified.

If emergent suicide care is recommended by the VCL at a non-VA facility, then

the VCL must notify the SPC and the Office of Community Care at the nearest

VAMC.

If the eligible individual receives emergent suicide care at a non-VA facility, without the VCL recommendation, then the Secretary must notify the SPC and

the Office of Community Care at the nearest VAMC regarding the eligible

individual, or someone else must notify the Secretary on behalf of the individual

within seven days of receiving the emergent suicide care.

After emergent suicide care is provided, as soon as practicable, the Secretary

must make referrals to other VA benefits and services as appropriate and

determine the eligibility for those benefits and services.

Prohibition on Charges

This section provides that the Secretary may not impose any charges for emergent suicide care (i.e., no “cost sharing” or “out-of-pocket” costs), and must pay for any costs of emergency

transportation. The Secretary may not impose any charges, even if the eligible individual, or

someone else on behalf of the individual, did not notify the Secretary within the seven day notification period.

Reimbursement and Other Health Insurance

This section stipulates that the Secretary could establish payment rates for care in non-VA

facilities or from non-VA providers in a similar manner to the manner in which the Secretary

determines reimbursement amounts for that nondepartment facility for medical care and services

provided under another provision of this chapter. If the eligible individual has a health plan

contract that would pay for the emergent suicide care treatment, the Secretary may recover the costs for nonservice-connected emergent suicide care from such third party.

Annual Report to Congress

This section requires the Secretary to submit and report annually to SVAC and HVAC. The report

must include the number of eligible individuals who received emergent suicide care and related demographic information, the types of care provided, and the total cost of emergent suicide care.

Definitions

This section defines the following terms applicable to the new “Emergent suicide care” section.

Acute suicidal crisis. An individual who is determined by a trained crisis responder or health care provider to be at imminent risk of self-harm.



Crisis residential care. Care provided in a residential setting, and in a nonhospital facility.

Crisis stabilization care. Care provided to an individual in acute suicidal crisis, which would provide immediate safety and reduce the severity of the distress.

Emergent suicide care. Crisis stabilization care provided based on recommendations from the VCL or when presented at a medical facility with acute suicidal crisis.

Health-plan contract. A private health insurance policy or contract, Medicare, Medicaid, or workers’ compensation law or plan.

Effective Date

This new section will be effective 270 days after the date of the enactment of this act (i.e., September 1, 2021).

Section 202: Education Program for Family Members and Caregivers of

Veterans with Mental Health Disorders

Background

The Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (P.L. 107-

135) first authorized VHA to provide services such as counseling, training, and mental health

services to family members of veterans receiving treatment through VA. Eligibility for these

services was later expanded to caregivers by the Caregivers and Veterans Omnibus Health

Services Act of 2010 (P.L. 111-163). Under these authorities, VHA established policies for providing services to family members and caregivers as they pertain to a veteran’s mental health

goals.213 Such services include, at a minimum, family education, veteran-centered brief family consultation, and marital and family counseling, including family psychoeducation.

Provision

Section 202 requires the Secretary to establish an education pilot program for family members and caregivers on matters related to coping with mental health disorders in veterans. The

Secretary is required to establish the program no later than 270 days after enactment (i.e.,

September 1, 2021), and the program is required to continue for four years from the date of

commencement. The component of the program that relates to education and training of

noncaregiver family members must be carried out in at least five medical centers, at least five clinics, and at least five vet centers.

This section requires that the Secretary contract with nonprofit entities experienced in the relevant

field to carry out the education program as specified. In addition, the Secretary is required to select department mental health care providers to monitor the progress of instruction under the

program. The curriculum must consist of, among other things (1) general education on different

mental health disorders, (2) techniques for handling crisis situations and administering mental

health first aid, (3) techniques for coping with the stress of living with an individual suffering from a mental health disorder, and (4) information on additional services available.

The Secretary is required to survey participants for satisfaction, perceived effectiveness, and

applicability of the program to issues faced. In addition, the Secretary is required to submit an

annual report to HVAC and SVAC no later than one year after commencement of the program and

213 Department of Veterans Affairs, Veterans Health Administration, Family Services in Mental Health , VHA Directive

1163.04, June 17, 2019.



no later than September 30 each year thereafter until 2024. The section specifies information to

include in the annual report, which includes results of the surveys. Furthermore, the Secretary is

required to submit a final report to HVAC and SVAC no later than one year after the completion of the program.

Section 203: Interagency Task Force on Outdoor Recreation for Veterans

Background

Some research suggests that outdoor recreation, such as camping or kayaking, may prove

beneficial for veterans with mental health problems.214 Further, group-based outdoor recreation programs may help veterans who are transitioning back to civilian life.215

In May 2019, legislation was jointly introduced in the House and Senate that would have created a federal interagency task force on outdoor recreation for veterans.216 In July 2020, HVAC held a

legislative hearing on the House-passed version of the bill.217 VA supported the passage of the bill

but had a few suggestions for technical corrections.218 Organizations such as the Paralyzed

Veterans of America and the Iraq and Afghanistan Veterans of America also supported the passage of the legislation.219

Provision

Section 203 requires the Secretary to establish the Task Force on Outdoor Recreation for Veterans

(Task Force) no later than 18 months after the President’s national emergency declaration

pertaining to Coronavirus Disease 2019 (COVID-19) expires.220 The Task Force must include

representatives from the Departments of the Interior, Health and Human Services, Agriculture, Defense, and Homeland Security, as well as the Army Corps of Engineers, at least two

representatives from VSOs, and any other member the Secretary deems appropriate. The

Secretary and Secretary of the Interior are required to serve as co-chairpersons of the Task Force.

214 Department of Veterans Affairs, “Outdoor activities improve mental health in Veterans, study finds,” February 19,

2014, https://www.research.va.gov/currents/winter2013-14/winter2013-14-25.cfm.

215 Jason Duvall and Rachel Kaplan, Exploring the Benefits of Outdoor Experiences on Veterans, University of

Michigan and Sierra Club, Washington, DC, June 2013, p. 23,

https://content.sierraclub.org/outings/sites/content.sierraclub.org.outings/files/SIERRA_REPORT_6_13_Exploring%20

the%20benefits%20of%20outdoor%20expereinces%20on%20veterans%20(1).pdf. 216 S. 1263 (116th Congress) and H.R. 2435 (116th Congress).

217 U.S. Congress, House Committee on Veterans’ Affairs, Legislative Hearing on: H.R. 6039; H.R. 6082 ;H.R.

4908;H.R. 2791; H.R. 4526; H.R. 3582 ; H.R. 96 ; H.R. 4281; H.R. 3010 ; H.R. 7163; H.R. 7111; H.R. 2435; H.R.

7287; H.R. 3228; H.R. 6141; H.R. 6493 ; H.R. 7445; Discussion Draft –Burial Equity for Guards and Reserves Act of

2020; Discussion Draft – To amend title 38, United States Code, to extend certain employment and reemployment

rights to members of the National Guard who perform State active duty, an d Discussion Draft – To amend title 38,

United States Code, to clarify the scope of procedural rights of members of the uniformed services with respect to their

employment and reemployment rights, and for other purposes, 116th Cong., 2nd sess., July 23, 2020. 218 U.S. Congress, House Committee on Veterans’ Affairs, Testimony for the House Committee on Veteran’s Affairs,

prepared by Dr. Maria Llorente, Veterans Health Administration, 116 th Cong., 2nd sess., July 23, 2020.

219 See for example U.S. Congress, House Committee on Veterans’ Affairs, Statement for the Record for the House

Committee on Veteran’s Affairs, prepared by Ryan Britch, Iraq and Afghanistan Veterans of America, 116 th Cong., 2nd

sess., July 23, 2020, and U.S. Congress, House Committee on Veterans’ Affairs, Statement for the Record for the

House Committee on Veteran’s Affairs, prepared by Paralyzed Veterans of America, 116 th Cong., 2nd sess., July 23,

2020. 220 50 U.S.C. §§1601 et seq.



Section 203(g) states that the Federal Advisory Committee Act (FACA; P.L. 92-463) is not applicable to the Task Force.

Section 203(d) stipulates the duties of the Task Force, which must be carried out in consultation with appropriate veteran outdoor recreation groups. Among other things, the Task Force is

required to identify barriers that exist to providing veterans with health and wellness services

through use of outdoor recreation on public lands and to develop recommendations to better

accommodate the use of public lands for this purpose. Section 203(h) defines public lands as any recreational lands under federal, state, or local government jurisdiction.

Section 203(e) requires submission of reports to Congress on the findings of the Task Force. A

preliminary report on initial findings of the Task Force is due no later than one year after the date

on which the Task Force is established. The final report, which is required to include recommendations developed under subsection (d), must be submitted no later than one year after

the submission of the preliminary report. Pursuant to section 203(f), the Task Force is required to end one year after the submission of the final report under subsection (e).

Section 204: Contact of Certain Veterans to Encourage Receipt of

Comprehensive Medical Examinations

Background

In general, a veteran must be enrolled in the VA health care system as a condition for receiving

care. Once a veteran is enrolled, the veteran remains in the system and does not have to reapply

for enrollment annually. However, in a given year not all enrolled veterans receive care through the VA health care system, either because they are not sick or have other sources of health care coverage such as private health insurance or public sources such as Medicare.221

Provision

Section 204 requires the Under Secretary of Health to contact all enrolled veterans who have not

received care from the VA health care system in the past two years and encourage them to receive a comprehensive medical examination, including mental health evaluations and specified vision

and hearing tests. The veteran could receive this examination in a VAMC or in the community

under the VCCP.222 When care is provided in a VAMC, the Secretary must seek to schedule all

examinations on the same day. Eligible veterans are to be contacted by mail, telephone, or email

no later than 90 days after enactment of this act (i.e., March 5, 2021). This section allows the

Secretary to pay for travel for rural covered veterans who avail themselves of this comprehensive medical examination, as well as to enter into contracts for shuttle services to transport veterans in

rural areas to receive the examination. This section requires a report to Congress no later than 18

months after enactment (i.e., June 5, 2022) on how many eligible veterans scheduled comprehensive medical examinations.

221 For more information, see CRS In Focus IF10418, Do Veterans Have Choices in How They Access Health Care?

222 For more information on VCCP, see CRS Report R45390, VA Maintaining Internal Systems and Strengthening

Integrated Outside Networks Act of 2018 (VA MISSION Act; P.L.115-182).



Section 205: Police Crisis Intervention Training of Department of

Veterans Affairs

Background

VA police officers are federal law enforcement officers who provide security and law

enforcement services at VHA facilities, VBA offices co-located with VHA facilities, and for VA national cemeteries under certain circumstances.223 There are approximately 4,000 police officers

working at 139 of the 141 VAMCs, and VHA shares responsibility for the police program with

the VA Office of Operations, Security, and Preparedness (OSP).224 All VA police officers receive

specialized training at the Law Enforcement Training Center (LETC), accredited by the Federal Law Enforcement Training Accreditation Board. This training entails

a 10-week basic training course where they receive 30.5 hours of classroom training specific to de-escalation and conflict management techniques with a new special focus on

suicide awareness and prevention. Officers also complete nearly 24 hours of practical based scenarios in which they are expected to successfully employ and utilize de-escalation skills

to affect positive outcomes in real-life scenarios.225

In light of incidents involving veterans with mental health conditions being mistreated and

injured by VA police,226 among other reasons, the HVAC Subcommittee on Oversight and

Investigations held a June 2019 hearing on current VA police policies and procedures. 227 A bill

was subsequently introduced in the House that would, among other things, amend current law228

to require VA police officers to receive annual training on preventing suicide among the population served (i.e., veterans).229

Provision

Section 205(a) requires the Secretary to provide department police officers with an annual

training on veteran suicide prevention. Section 205(f) defines department police officers as employees of VA under 38 U.S.C. §902(a). Section 205(b) requires that the Secretary update any

training already provided before enactment to include, at minimum, (1) effective behavioral

procedures of suicide prevention and risk mitigation; (2) crisis intervention and de-escalation

skills through the use of interactive training; (3) information about mental health and substance

use disorders; and (4) information about local law enforcement teams and other resources for

veterans experiencing mental health crises. Section 205(c) requires that the training occur at a

223 38 U.S.C. §902(a), and VA OIG, VA Police Management System Needs Improvement, Department of Veterans

Affairs, June 17, 2020, https://www.va.gov/oig/pubs/VAOIG-19-05798-107.pdf. 224 U.S. Congress, House Committee on Veterans’ Affairs, Testimony before the House Committee on Veteran’s

Affairs, Subcommittee on Oversight and Investigations, Examining the Department of Veteran s Affairs Police Program,

prepared by Michael J. Missal, Department of Veterans Affairs Inspector General, 116 th Cong., 1st sess., June 11, 2019,

p. 2.

225 U.S. Congress, House Committee on Veterans’ Affairs, Testimony before the House Committee on Veteran’s

Affairs, Subcommittee on Oversight and Investigations, Examining the Department of Veterans Affairs Police Program,

prepared by Renee Oshinski, Deputy Under Secretary for Health for Operations and Management (Acting), Veterans

Health Administration, 116 th Cong., 1st sess., June 11, 2019, p. 4. 226 U.S. Representative Kathleen Rice, “ Rice, Pappas Introduce VA Police Reform Legislation ,” July 24, 2020,

https://kathleenrice.house.gov/news/documentsingle.aspx?DocumentID=1548.

227 U.S. Congress, House Committee on Veterans’ Affairs, Subcommittee on Oversight and Investigations, Examining

the Department of Veterans Affairs Police Program , 116th Cong., 1st sess., June 11, 2019.

228 38 U.S.C. §902. 229 H.R. 7784 (116th Congress).



VAMC in consultation with the mental health experts at the VAMC, as well as law enforcement

training accreditation organizations. Section 205(d) requires that each VA facility police force

develop a plan to enter into partnerships with relevant local community organizations and local police departments.

Section 205(e) requires the Secretary to submit to HVAC and SVAC, no later than one year after

enactment (i.e., December 5, 2021), a report with specified information on the annual training and partnerships required under this section.

Title III: Improvement of Care and Services for Women Veterans

Section 301: Gap Analysis of Department of Veterans Affairs Programs That

Provide Assistance to Women Veterans Who Are Homeless

Background

Based on a single day count in January 2020, approximately 8.4% of veterans experiencing

homelessness were women.230 Programs to assist homeless veterans are funded through three

agencies: VA, Department of Labor (DOL), and Department of Housing and Urban Development

(HUD). Although not necessarily specific to women veterans, a number of VA-administered

programs conduct outreach to homeless veterans, provide work experience, issue grants for housing, and provide supportive services for low-income families.231

Provision

Section 301 requires the Secretary to complete a gap analysis232 of the programs available

through VA that provide assistance to women veterans who are experiencing homelessness or

who are precariously housed. The Secretary is required to submit a report on the analysis to HVAC and SVAC no later than 270 days after enactment (i.e., September 1, 2021).

Section 302: Report on Locations Where Women Veterans Are Using Health

Care from Department of Veterans Affairs

Background

VA administers a women’s health care program that, among other things, offers outreach and support to women veterans to put them in touch with available VHA health services. VHA offers

enrolled veterans a standard medical benefits package, which includes a full range of health care,

gender-specific medical services, prescription drugs, long-term care, and social support

services.233 Gender-specific health care services include primary health care, intimate partner

230 Department of Housing and Urban Development, The 2020 Annual Homeless Assessment Report (AHAR) to

Congress, January 2021, p. 54, https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf. 231 For more information on veteran homelessness programs, see CRS In Focus IF10167, Veterans and Homelessness.

232 For the purposes of this section, gap analysis is intended to identify the areas in which the relevant programs are

failing to meet the needs of women veterans who are experiencing homelessness or who are precariously housed.

233 38 C.F.R. §17.38.



violence services, military sexual trauma services, and maternity health care services, among others.234

Provision

Section 302 requires the Secretary to submit a report no later than 90 days after enactment (i.e.,

March 5, 2021), and annually thereafter, to HVAC and SVAC on the use of VHA care by women veterans. This report must include (1) the number of women veterans who reside in each state; (2)

the number of women veterans enrolled in the VA health care system in each state; (3) the number

of enrolled women veterans who received care at least during the one-year period; (4) the number

of women veterans who were seen at each VA medical facility; (5) the number of appointments

for women veterans disaggregated by facility and appointment type; (6) the number of

appointments completed in person and through telehealth; (7) identification of the medical facility in each VISN with the largest rate of increase in women veteran patient population; and (8)

identification of the medical facility in each VISN with the largest rate of decrease in women veteran patient population.

234 For more information on gender-specific health care for women veterans, see CRS In Focus IF11082, Veterans

Health Administration: Gender-Specific Health Care Services for Women Veterans.



Appendix. Implementation Dates, Reporting

Requirements, and Deadlines The tables below include relevant provisions for the Hannon Act and the Veterans COMPACT

Act, respectively, which include an effective date, a required report, or an explicit sunset date. The tables include only reports that must be made public or be delivered to Congress. This CRS

report reflects the Hannon Act and the Veterans COMPACT Act at enactment and will not track actions pursuant to these deadlines, nor will this report be updated.

Table A-1. Hannon Act Implementation Dates, Reporting Requirements,

and Deadlines

Section Number Brief Description

Effective Date/Reporting

Deadline

Title I. Improvement of Transition of Individuals to Services from Department of Veterans Affairs

Section 101 Requires the Secretary, in

consultation with the Secretary of

Defense, to develop a strategic plan

for providing health care to

veterans transitioning from service,

to be submitted to specified

congressional committees and

published on the VA website.

No later than one year after

enactment (i.e., by October 17,

2021).

Section 102 Requires the Secretary of Defense

and the Secretary to submit a joint

report, to specified congressional

committees, on their review of the

records of all members of the

Armed Forces who died by suicide

within one year of discharge/release

during the five-year period

preceding enactment (i.e., October

17, 2015 to October 17, 2020).

No later than three years after


2023).

Section 103 Requires the Secretary to submit a


committees, on the REACH VET

program.

No later than 180 days after

enactment (i.e., by April 15, 2021).

Section 104 Requires the Secretary to annually

submit a report, to specified

congressional committees, on the

mental and behavioral health care

services provided to

servicemembers who were

discharged or released with an

OTH discharge.

No later than February 15 each

year.

Title II. Suicide Prevention





Deadline



committees, on the grant criteria,

measures and metrics, and

information sharing framework of

the Staff Sergeant Parker Gordon

Fox Suicide Prevention Grant

Program.

No later than 30 days before

notifying eligible entities of the

availability of grant funding.

Requires the Secretary to submit an

interim report, to specified


provision of grants under the Staff

Sergeant Parker Gordon Fox

Suicide Prevention Grant Program.

No later than 18 months after the

date on which the first grant is

awarded.

Requires the Secretary to submit a

final report, to specified


provision, effectiveness, and

potential extension or expansion of

grants under the Staff Sergeant

Parker Gordon Fox Suicide

Prevention Grant Program.

No later than three years after the


awarded, and annually thereafter for

each year in which the program is in

effect.

Requires the Secretary to seek to

enter into a contract with a

nongovernment entity to conduct a

third-party assessment of the Staff

Sergeant Parker Gordon Fox

Suicide Prevention Grant Program.


commencement of the grant

program.

Requires the Secretary to submit

the third-party assessment to

specified congressional committees.



awarded.

Sunset of the Staff Sergeant Parker

Gordon Fox Suicide Prevention

Grant Program.

Three years after the date on which

the first grant is awarded.

Section 202 Requires the Secretary to complete

an analysis and submit a report, to

specified congressional committees,

on the feasibility and advisability of

providing select complementary and

integrative health treatments at all

VA medical facilities.



Section 203 Requires the Secretary to

commence a pilot program to

provide select complementary and

integrative health programs to

eligible veterans.

No later than 180 days after the

COVER Commission submits its

final report (i.e., by July 24, 2020).


interim report, to specified


pilot program.

No later than one year after the

commencement of the pilot

program.





Deadline




pilot program.


termination of the pilot program.

Sunset of the pilot program. Three years after the


program.a

Section 204 Requires the Secretary to brief

specified congressional committees

on the interim results of a VA and

NASEM study on the effects of

opioids and benzodiazepine on all-

cause mortality of veterans,

including suicide.

No later than 24 months after VA

enters into an agreement with

NASEM for the study.

Requires GAO to conduct a review

of the staffing levels for mental

health professionals at VA.


enactment (i.e., January 15, 2021).

Requires the Secretary to brief


on the interim results of the GAO

review of the staffing levels for

mental health professionals at VA.

No later than 18 months after



publically available report, to


on the results of a VA and NASEM

study on the effects of opioids and

benzodiazepine on all-cause

mortality of veterans, including

suicide.


completion of the study.


publically available report, to


on the results of the GAO review

of the staffing levels for mental

health professionals at VA.


completion of the GAO review.

Section 205 Requires a GAO report, submitted

to specified congressional

committees, on the efforts of VA to

manage veterans at high risk for

suicide.



Title III. Programs, Studies, and Guidelines on Mental Health


consultation with Rural Health

Resource Centers of the Office of

Rural Health of VA, to commence a

study on the connection between

living at high altitude and the risk of

depression or suicide among

veterans.







Deadline

Deadline for the completion of the

study.


commencement of the study.



committees, on the results of the

study.


completion of the study.

If the Secretary determines, through

the study, that living at high altitude

is a risk factor for depression or

suicide, the Secretary is required to

conduct a follow-up study on (1)

the most likely biological mechanism

that makes living at high altitude a

risk factor for depression or suicide

and (2) the most effective treatment

or intervention for reducing the risk

of depression or suicide associated

with high altitude.

If the follow-up study is conducted,

the Secretary is required to submit

a report, to specified congressional

committees, on the results of that

study.

Report due no later than 150 days

after the completion of the follow-

up study.



Defense, to develop a clinical

provider treatment toolkit and

accompanying training materials for

comorbidities of mental health

conditions, substance use disorders,

and chronic pain.

No later than two years after


2022).

Section 303 Requires the Secretary and the

Secretary of Defense to update

guidance in VA and Department of

Defense Clinical Practice Guideline

for Assessment and Management of

Patients at Risk for Suicide.

Update required in the first

publication after enactment.b



Defense and the Secretary of Health

and Human Services, to develop

clinical practice guidelines for the

treatment of serious mental illness.



2022).

Requires the Secretary, in


Defense and the Secretary of Health

and Human Services, to assess the

2016 Clinical Practice Guidelines for

the Management of Major

Depressive Disorders and

determine if updates are necessary.



2022).





Deadline

Section 305 Requires the Secretary to develop

and implement an initiative to

identify and validate brain and

mental health biomarkers among

veterans.



Title IV. Oversight of Mental Health Care and Related Services

Section 401 Requires the Secretary to contract

with a nonfederal government entity

to complete a study using focus

groups on the effectiveness of the

mental health and suicide

prevention outreach materials and

campaigns conducted by VA.





committees, on the findings of the

study.

No later than 90 days after the last

focus group meeting of the study.

Requires the Secretary to complete

a representative survey of veterans

to collect information about the

effectiveness of the mental health

and suicide prevention outreach

materials and campaigns conducted

by VA.

No later than one year after the last

focus group meeting of the study on

effectiveness of mental health and

suicide prevention outreach

materials and campaigns conducted

by VA.

Section 402 Requires the Secretary to submit an

initial report, to specified


established goals, metrics, and

targets of the mental health and

suicide prevention media outreach

campaigns conducted by VA.




annual report, to specified


progress of VA in meeting the goals

of its mental health and suicide

prevention media outreach

campaigns, as well as actions to be

taken to better meet those goals.


submittal of the initial report, and

annually thereafter.



committees, containing the

expenditures and obligations of the

Office of Mental Health and Suicide

Prevention of the Veterans Health

Administration during the period

covered by the report.


enactment (i.e., by April 15, 2021),

and semiannually thereafter.

Section 403 Requires GAO to submit a

management review, to specified

congressional committees, of the

mental health and suicide

prevention services provided by VA.

No later than three years after


2023).





Deadline




integrate mental health care into

primary clinics of the Department.



2022).

Requires a GAO report, submitted



integrate community-based mental

health care into the Veterans Health

Administration.

No later than two years after the

submittal of the GAO report on

integrating mental health care into

primary care clinics.

Section 405 Requires the Secretary and

Secretary of Defense to submit an



mental health programs and joint

mental health programs conducted

by VA and the Department of

Defense.



2021), and annually thereafter.



committees, on (1) the evaluation of

collaborative efforts by VA and the

Department of Defense related to

PTSD and traumatic brain injuries;

(2) the potential for new

collaborative efforts to improve

such care through a joint

VA/Department of Defense Intrepid

Spirit Center; and (3) an alternatives

of analysis to establish the joint

VA/Department of Defense Intrepid

Spirit Center.


enactment (i.e., by July 14, 2021).

Title V. Improvement of Mental Health Medical Workforce


consultation with the Inspector

General of VA, to submit a plan, to


to address staffing of mental health

providers at VA.



2021).



committees, that contains the

number of mental health providers

hired by VA during the one-year

period preceding the report.


submittal of the plan.


consultation with the Office of

Personnel Management, to develop

an occupational series for licensed

professional mental health

counselors and marriage and family

therapists of VA.



2021).





Deadline

Section 502 Effective period for the VA

Readjustment Counseling Service

Scholarship Program.

Scholarships are to begin being

awarded no later than one year

after enactment (i.e., by October

17, 2021).



committees, on VA Readjustment

Counseling Service.



2021).

Section 504 Requires the Secretary to submit, to


a biennial supplement to the annual

report on the Readjustment

Counseling Service.

Each even-numbered year in which

the annual report on the

Readjustment Counseling Service is

submitted (i.e., no later than March

15 of each even numbered year).

Section 505 Requires the Secretary to conduct a

survey on the attitudes of eligible

veterans toward VA offering

appointments outside the usual

operating hours of facilities of the

department.



Requires the Secretary to brief


on the feasibility, advisability, and

effectiveness of offering

appointments outside the usual

operating hours of facilities of VA.


enactment (i.e., by July 14, 2021).

Section 506 Requires that every medical center

of VA has at least one suicide

prevention coordinator.

Beginning no later than one year

after enactment (i.e., by October

17, 2021).


consultation with the Office of

Mental Health and Suicide

Prevention, to commence a study

on the feasibility and advisability of

(1) the reorganization of suicide

prevention coordinators within the

Office of Mental Health and Suicide

Prevention and (2) the creation of a

suicide prevention coordinator

program office.



2021).



committees, on (1) the results of

the study, (2) the staffing ratios for

suicide prevention coordinators and

case managers at VA, and (3) the

responsibilities of suicide prevention

coordinators across the

department.


completion of the study on suicide

prevention coordinators.





Deadline



committees, on the efforts of the

Secretary to implement a suicide

prevention program for veterans

presenting to a Veterans Health

Administration emergency

department/urgent care center who

are assessed to be at risk for suicide

but are safe to be discharged home.



Title VII. Other Matters


an assessment of barriers faced by

veterans in accessing telehealth

services.






assessment, as well as any

recommendations for legislative or

administrative action.


completion of the assessment.


consultation with the Center for

Compassionate Innovation, to begin

reviewing the effectiveness and

applicability of hyperbaric oxygen

therapy.


enactment (i.e., by January 15,

2021).



Compassionate Innovation, to

conduct a systematic review of

published research literature on off-

label use of hyperbaric oxygen

therapy to treat PTSD and

traumatic brain injury among

veterans and nonveterans.

Review must commence no later

than 90 days after enactment (i.e.,

by January 15, 2021).

Review must be completed no later

than 180 days after commencement.




review.


completion of the review.



Compassionate Innovation, to

conduct a follow-up study on all

individuals receiving hyperbaric

oxygen therapy for the treatment of

PTSD and traumatic brain injury

through the current VA pilot

program.

Study must commence no later than

120 days after the completion of the

review.

Study must be completed no later

than three years after

commencement.





Deadline




follow-up study.


completion of the follow-up study.

Section 703 Requires the Secretary to prescribe

technical qualifications for the

appointment of licensed hearing aid

specialists in the Veterans Health

Administration.



Requires the Secretary to appoint at

least one licensed hearing aid

specialist at each VA medical center.

No later than September 30, 2022.



committees, on (1) progress and

conflicts/obstacles in appointing

licensed hearing aid specialists at

VA, (2) patient access to

comprehensive hearing health care

services at VA, and (3) vacancies for

audiologists or licensed hearing aid

specialists at VA medical centers.

No later than September 30, 2022,

and annually thereafter.


all necessary policy revisions to

allow VA-sponsored clinical

research to use accredited

commercial institutional review

boards to review VA research

proposal protocols.


enactment (i.e., by January 15,

2021).

Requires the Secretary to (1)

identify accredited commercial

institutional review boards for use

in connection with VA-sponsored

clinical research and (2) establish a

process to modify existing approvals

in the event that a commercial

institutional review board loses its

accreditation during an ongoing

clinical trial.


completion of the policy revisions.



congressional committees, on all

approvals of institutional review

boards used by VA.


completion of the policy revisions,

and annually thereafter.

Section 705 Requires the Secretary to establish

an Office of Research Reviews

within the VA Office of Information

and Technology.



2021).

Requires the Office of Research

Reviews to submit a report, to


on the activity of the office.


establishment of the Office.



Source: CRS analysis of the Commander John Scott Hannon Veterans Mental Health Care Improvement Act of

2019 (P.L. 116-171).

Notes: Effective dates are not included for reporting deadlines that are based on the date of completion of

another reporting deadline.

COVER = Creating Options for Veterans’ Expedited Recovery; GAO = U.S. Government Accountability Office;

NASEM = National Academies of Sciences, Engineering, and Medicine; OTH = Other Than Honorable; PTSD =

Posttraumatic Stress Disorder; REACH VET = Recovery Engagement and Coordination for Health – Veterans

Enhanced Treatment; Secretary = Secretary of the Department of Veterans Affairs; VA = Department of

Veterans Affairs.

a. The Secretary may extend the pilot program beyond three years if the Secretary, based on the results of

the interim report submitted to the House and Senate Veterans Affairs Committees, determines it is

appropriate to do so.

b. The most recent update to the VA and Department of Defense Clinical Practice Guideline for Assessment

and Management of Patients at Risk for Suicide was published in May 2019 and based on evidence reviewed

through April 2018. Department of Veterans Affairs, “VA/DoD Clinical Practice Guideline for Assessment

and Management of Patients at Risk for Suicide,” May 2019, at https://www.healthquality.va.gov/guidelines/

MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf.

Table A-2. Veterans COMPACT Act Implementation Dates, Reporting Requirements, and Deadlines



Deadlines

Title I. Improvement of Transition of Individuals to Services from Department of Veterans Affairs

Section 101 Requires the Secretary to

commence a voluntary pilot

program that connects veterans

transitioning from service with

designated individuals to help share

information regarding assistance and

benefits available to those veterans.


enactment (i.e., by December 5,

2021).

Requires the Secretary to

administer surveys in order to

receive feedback from individuals

who elected to receive information

under the pilot program.



program, and not less frequently

than annually thereafter for the

duration of the pilot program.




pilot program.



program.

Duration of the pilot program. The pilot program must be carried

out for a period not less than two

years.




VA Solid Start program.


enactment (i.e., by June 3, 2021),

and annually thereafter for five

years.

Title II. Suicide Prevention



congressional committees, on

emergent suicide care provided by

VA.

Not less than once each year.





Deadlines

Effective date for the furnishing

and/or payment of emergent suicide

care by VA.

Begins 270 days after enactment

(i.e., on September 1, 2021).


an education program for the

education and training of caregivers

and family members of eligible

veterans with mental health

disorders.

Not less than 270 days after

enactment (i.e., by September 1,

2021).




education program and the

feasibility and advisability of

expanding the education program to

include a peer support program.


commencement of the education

program and no later than

September 30 each year thereafter

until 2024.




feasibility and advisability of

continuing the education program.


completion of the education

program.

Duration of education program. Four-year period following the

commencement of the education

program.


an interagency task force on

outdoor recreation for veterans.


expiration of the national

emergency pertaining to COVID-

19.a

Requires the chairpersons of the

Task Force to submit a report to

Congress on the preliminary

findings of the Task Force.


Task Force is established.

Requires the chairpersons of the

Task Force to submit a report to

Congress on the final findings and

recommendations of the Task

Force.


submittal of the preliminary report.

Sunset of Task Force. One year after the submittal of the

final report.

Section 204 Requires the VA Under Secretary of

Health to seek to contact all

covered veterans in order to

encourage them to receive

comprehensive medical

examinations.


enactment (i.e., by March 5, 2021).





Deadlines


report to Congress regarding how

many covered veterans scheduled

comprehensive medical

examinations after receiving the

communication described in this

section.


enactment (i.e., by June 5, 2022).



committees, regarding the annual

training of VA police officers on the

prevention of suicide among their

served population.


enactment (i.e., by December 5,

2021).

Title III. Improvement of Care and Services for Women Veterans



committees, on the analysis of VA

programs that provide assistance to

women veterans who are homeless

or precariously housed.


enactment (i.e., by September 1,

2021).



congressional committees, on

women veterans’ use of health care

from VA.


enactment (i.e., by March 5, 2021).

Source: CRS analysis of the Veterans COMPACT Act of 2020 (P.L. 116-214).

Notes: Effective dates are not included for reporting deadlines that are based on the date of completion of

another reporting deadline.

COVID-19 = Coronavirus Disease 2019; Secretary = Secretary of the Department of Veterans Affairs; VA =

Department of Veterans Affairs.

a. 50 U.S.C. §§1601 et seq.

Author Information

Victoria R. Green, Coordinator Analyst in Health Policy

Amanda K. Sarata Specialist in Health Policy

Sidath Viranga Panangala

Specialist in Veterans Policy

Bryce H. P. Mendez

Analyst in Defense Health Care Policy

Jared S. Sussman Analyst in Health Policy

Isaac A. Nicchitta Research Assistant


Congressional Research Service R46848 · VERSION 2 · NEW 75

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